3  Antibiotic resistance in humans

3.1 Overview of surveillance systems and methods for antibiotic susceptibility testing

All surveillance of antibiotic resistance in Sweden relies on results from the clinical microbiology laboratories. The laboratories use the methods and breakpoints recommended by the Nordic Committee on Antimicrobial Susceptibility Testing (NordicAST) for susceptibility testing (European Committee on Antimicrobial Susceptibility Testing (EUCAST) 2025). This Nordic organisation supports implementing European Committee on Antimicrobial Susceptibility Testing (EUCAST) recommendations in the Nordic countries. National resistance surveillance is based on data from different sources and collections Table 3.1.

Table

Table 3.1. Summary of species and types of resistance included in national sureveillance of antibiotic resistance in Sweden.

Surveillance type	Species, group or type	Sampling
Mandatory reporting (Sminet)	Enterobacterales with ESBL	Samples of all types for clinical, screening or case finding purposes.
Mandatory reporting (Sminet)	Enterobacterales with ESBLCARBA	Samples of all types for clinical, screening or case finding purposes.
Mandatory reporting (Sminet)	Staphylococcusaureus resistant to methicillin	Samples of all types for clinical, screening or case finding purposes.
Mandatory reporting (Sminet)	Streptococcuspneumoniae with reduced susceptible to benzylpenicillin	Samples of all types for clinical, screening or case finding purposes.
Mandatory reporting (Sminet)	Enterococcus faecium or Enterococcus faecalis resistant to vancomycin	Samples of all types for clinical, screening or case finding purposes.
Mandatory reporting (Sminet)	Mycobacterium tuberculosis	Samples of all types for clinical, screening or case finding purposes.
Mandatory reporting (Sminet)	Neisseria gonorrhoeae	Samples of all types for clinical, screening or case finding purposes.
Mandatory reporting (Sminet)	Neisseria meningitidis	Invasive disease (blood, CSF, or other normally sterile sample).
Mandatory reporting (Sminet)	Clostridioides difficile	Volontary
Voluntary surveillance (Svebar)	Escherichia coli	Clinical sampling from blood and urine.
Voluntary surveillance (Svebar)	Klebsiella pneumonia	Clinical sampling from blood and urine.
Voluntary surveillance (Svebar)	Staphylococcus aureus	Clinical sampling from blood and skin and soft tissue infections.
Voluntary surveillance (Svebar)	Streptococcus pneumoniae	Clinical sampling from blood.
Voluntary surveillance (Svebar)	Enterococcus faecalis	Clinical sampling from blood.
Voluntary surveillance (Svebar)	Enterococcus faecium	Clinical sampling from blood.
Voluntary surveillance (Svebar)	Pseudomonas aeruginosa	Clinical sampling from blood and non respiratory infections.
Voluntary surveillance (Svebar)	Acinetobacter spp.	Clinical sampling from blood.
Voluntary surveillance (Svebar)	Haemophilus influenza	Clinical sampling from blood and nasopharynx.
Voluntary surveillance (Svebar)	Streptococcus pyogenes	Clinical sampling from blood.
Voluntary surveillance (Svebar)	Streptococcus agalacticae	Clinical sampling from blood.
Voluntary surveillance (Svebar)	Salmonella spp	Clinical sampling from blood, faeces and urine.
Voluntary surveillance (Svebar)	Campylobacter jejuni	Clinical sampling from faeces.
Voluntary surveillance (Svebar)	Shigella spp	Clinical sampling from faeces
Microbiological characterisation programme	Enterobacterales with ESBLCARBA	All isolates from clinical, screening or case finding samples producing ESBLCARBA.
Microbiological characterisation programme	Enterobacterales with resistance to cefiderocol, ceftazidim-avibactam, colistin, imipenem-relebactam or meropenem-vabrobactam	Isolates from clinical, screening or case finding samples.
Microbiological characterisation programme	Acinetobacter spp. with ESBLCARBA	All isolates from clinical, screening or case finding samples with reduced susceptibility to meropenem.
Microbiological characterisation programme	Acinetobacter spp. with resistance to cefiderocol	Isolates from clinical, screening or case finding samples.
Microbiological characterisation programme	Pseudomonas spp. with ESBLCARBA	All isolates from clinical, screening or case finding samples producing ESBLCARBA.
Microbiological characterisation programme	Pseudomonas spp. with resistance to cefiderocol	Isolates from clinical, screening or case finding samples.
Microbiological characterisation programme	Staphylococcus aureus resistant to methicillin	All cases from neonatal care, one representative isolate from healthcare-associated transmissions involving three or more patients, and all newly diagnosed cases within one month per year.
Microbiological characterisation programme	Streptococcus pneumoniae with oxacillin 1 µg < 9 mm (according to disc diffusion)	All isolates from clinical, screening or case finding samples.
Microbiological characterisation programme	Enterococcus faecium or Enterococcus faecalis resistant to vancomycin or linezolid	All isolates from clinical, screening or case finding samples.
Microbiological characterisation programme	Shigella sonnei resistant to cefotaxim/ceftazidim and ciprofloxacin	All isolates

Data

3.1.1 Indicators of antibiotic resistance

Since 2020, the proportions of cefotaxime resistant Escherichia coli (ESBL) and methicillin-resistant Staphylococcus aureus (MRSA) in blood isolates have been used as indicators for antibiotic resistance in Sweden. In 2023, the EU Council issued recommendations on tackling AMR. Targets for 2030 were set for each member state. Sweden’s targets, as described in the Council recommendation (Council of the European Union 2023), include a 3% reduction of the incidence of MRSA sepsis, a 10% reduction for the incidence of ESBL-producing E. coli sepsis and an unchanged incidence of carbapenem resistant Klebsiella pneumoniae sepsis, compared to 2019. Considering the observed trends for the indicators used since 2020, these are ambitious targets. The proportion of cefotaxime-resistant E. coli (ESBL) and methicillin-resistant Staphylococcus aureus (MRSA) in blood isolates have gradually increased over the last decade, reaching 9.0% and 2.4% in 2025, respectively (Figure 3.1).

Figure

Figure 3.1. Indicators of antibiotic resistance. Percentage of E. coli from blood cultures that are resistant to third-generation cephalosporins (cefotaxime, ESBL) and percentage of S. aureus from blood cultures that are resistant to cefoxitin (MRSA) from 2001 to 2025.

Data

Figure

Figure 3.2. Indicator for antibiotic resistance. Antibiotic resistance to cefotaxime in E. coli (ESBL) isolated from blood from women and men and in total during 2016-2025.

Data

Figure

Figure 3.3. Indicator for antibiotic resistance. Antibiotic resistance to cefoxitin in S. aureus (MRSA) isolated from blood from women and men and in total during 2016-2025.

Data

3.1.2 Notifiable diseases

Four types of antibiotic resistance in bacteria are included in the Swedish Communicable Diseases Act. These are Staphylococcus aureus resistant to methicillin (MRSA), Streptococcus pneumoniae resistant to penicillin (PRP), Enterococcus faecalis and Enterococcus faecium resistant to vancomycin (vanA or vanB, VRE) and Enterobacterales with ESBL (including AmpC) or ESBL_CARBA. However, ESBL and ESBL_CARBA are reported separately. As in previous years, the notifications of ESBL have greatly exceeded the other three (Figure 3.4 and Table 3.2).

Figure

Figure 3.4. Number of mandatory reported cases during 2021-2025.

Data

Table

Table 3.2. Summary of results for mandatory reported antibiotic resistance 2025.

Category	ESBL	ESBLCARBA	MRSA	PRP	VRE
Number of cases (incidence)	13 524 (128)	487 (4.6)	4 147 (39)	211 (2.0)	516 (4.9)
Proportion clinical infection (%)	71	35	56	0.6	0.09
Gender	67% women	51% men	52% women	58% men	61% men
Median-age (range)	59 years (0-95+)	60 years (0-95+)	36 years (0-95+)	56 years (0-94)	71 years ( 0–95+)
Proportion of domestic cases	No information	45% (8% no data)	63% (11% no data)	63% (29% no data)	77% (3% no data)
Short epidemiological information	Community and healthcare	Hospital abroad and domestic spread	Community	Community	Hospital, domestic spread
Bloodstream infections	1 149 (829 new cases 2025, 320 cases known from previous years)	36 (28 new cases 2025, eight cases known from previous years)	131 (108 new cases 2025, 23 cases known from previous years)	13	10

Data

Voluntary surveillance based on clinical samples

This surveillance is based on data collected from the regional clinical microbiology laboratories. Since 2015, all data on clinical isolates from humans have been collected through Svebar, an automated surveillance system that collects all culture results from participating clinical microbiology laboratories. Currently, 23 laboratories submit data to Svebar (May 2026). It is not possible to deduplicate data from Svebar since personal identification numbers are not included in the system. Consequently, duplicate findings from blood and other samples are included. Patients with highly resistant isolates tend to be sampled more frequently, which may lead to an overestimate of resistance levels in certain analyses (Table 3.3). Most antibiotic resistance levels presented in this report are based on non-selective susceptibility testing data from at least five laboratories, thus avoiding bias from hierarchical testing and regional differences. When the data presented are based on selective testing, this will be indicated in the graphs and tables. The 95% confidence intervals were calculated using the Wilson method (Wilson 1927) and are shown in all resistance data figures.

Data from Svebar are used for reporting both to EARS-Net (an ECDC surveillance system) and to GLASS (a WHO surveillance system). Prior to 2015, ResNet, a national surveillance programme on antibiotic resistance, was used to collect data. From 2015 and onwards, these yearly data are based on SIR reported by the clinical microbiology laboratories to Svebar.

Table

Table 3.3. Number of laboratories used for antibiotic resistance calculations during 2015-2025.

Variable	2015	2016	2017	2018	2019	2020	2021	2022	2023	2024	2025
Number of clinical microbiology laboratories	9	9	10	9	20	21	22	22	22	22	22
Coverage of population (%)	52	52	55	52	78	86	89	89	89	89	89

Data

Microbiological characterisation programmes

The Public Health Agency of Sweden provides microbiological characterisation programmes for verification and characterisation of isolates that participating laboratories send in. An overview is given in Table 3.1.

3.2 Overview of sampling and culture results

Denominator data comes from Svebar. Over the last four years (2022–2025), we included data from 22 clinical laboratories, covering approximately 90% of Sweden’s population. Figure 3.5 shows annual counts for blood cultures, urine cultures, nasopharyngeal cultures, and throat cultures. Reported culture numbers remained relatively stable throughout the period, with a slight decline in 2025 compared to 2024, partly due to one laboratory providing only 8 months of complete data. The number of bacteria reported to EARS-Net yearly is shown in Figure 3.6.

Figure

Figure 3.5. Annual analyses by culture type, 2022–2025.

Data

Figure

Figure 3.6. Number of isolates, collected from blood during 2021-2025, reported to EARS-Net.

Data

3.3 Escherichia coli, Klebsiella pneumoniae and other Enterobacterales with ESBL and ESBL_CARBA

3.3.1 Mandatory reporting of ESBL-producing Enterobacterales

Results

• Number of reported cases: 13 524 (previous year 12 527), relative change +8%.
• Number of bloodstream infections: 1 149 (previous year 1 055).

Trends

The ESBL incidence increased to 128 new cases per 100 000 inhabitants in 2025, see Figure 3.7. The increase was seen in clinical samples (urine, blood and cerebrospinal fluid (CSF)) and in samples taken for screening purposes (faeces, rectum and perineal). The number of bloodstream infections (BSI) with ESBL-producing Enterobacterales has increased steadily and 1 149 cases were reported in 2025 (Figure 3.8). Of these, 28% (n=320) were cases previously known to be carriers. E. coli was the most common cause of BSI at 77%, followed by K. pneumoniae at 20%.

The gender and age distribution has not changed much since the surveillance started and reflects the expected occurrence of urinary tract infections in the different groups. Children under one year of age (n=464, incidence 474) had the highest incidence, followed by the elderly, 85 years and older (n=1 353, incidence 445). The high incidence in neonates is probably a result of screening and contact tracing at neonatal units. Among the elderly, urinary tract infections are common bacterial infections explaining the high incidence in this group. As in previous years, the most commonly reported species was E. coli, found in 83% of all cases, followed by K. pneumoniae with 12%. The remaining cases comprised of several other species of Enterobacterales.

Figure

Figure 3.7. The incidence (cases/100 000 inhabitants) of cases with ESBL-producing Enterobacterales in relation to type of infection, year 2016–2025.

Data

Figure

Figure 3.8. Incidence (cases/100 000 inhabitants) of invasive cases with ESBL-producing Enterobacterales, reported during year 2016–2025.

Data

Clusters and outbreaks

ESBL-producing Enterobacterales are not included in the Public Health Agency of Sweden’s national microbial surveillance programme, but samples are accepted for typing on behalf of the regions, often in cases of suspected local outbreaks. In 2025, approximately 5% of all cases (573 isolates) were whole genome sequenced at the Agency and among these, 14 clusters or pairwise related cases (2–42 cases) of ESBL were detected based on whole genome sequencing and subsequent SNP-based analysis. The 14 clusters include 5 clusters that had one or more cases prior to 2025. Eight clusters with ESBL-producing Enterobacterales were caused by E. coli, four by K. pneumoniae, one by Enterobacter hormaechei and one by Klebsiella oxytoca. Nine of the clusters were suspected as healthcare-related and seven of these were linked to neonatal wards. Please note that suspected outbreaks are often investigated regionally and are therefore not included in these statistics.

Comments

The incidence of ESBL continued to increase in 2025 and has increased steadily since the COVID-19 pandemic. Continued increased travel outside of Sweden is believed to have contributed to the increase.

3.3.2 Mandatory reporting of ESBL_CARBA-producing Enterobacterales

Results

• Number of reported cases: 487 (previous year 410), relative change +19%
• Number of bloodstream infections: 36 (previous year 22)

Trends

In 2025, the incidence for ESBL_CARBA-producing Enterobacterales was 4.6 cases per 100 000 inhabitants, an increase with 19% compared to 2024. A majority, 60% of the cases, were carriers (Figure 3.9). Slightly more cases were reported as acquired abroad (47%, n=231) and were identified in connection with screening of patients after healthcare exposure abroad (n=110). Of the 219 domestic cases, 117 had a clinical infection. The proportion of domestic cases with healthcare-acquired ESBL_CARBA remained mainly at the same level as previous years (27%, n=60). For 117 domestic cases, information of acquisition was missing. The most common countries of infection in the notifications were Egypt (n=25), India (n=22), Turkey (n=19), Syria (n=15) and Iraq (n=14).

3.3.3 Microbiological surveillance programme, ESBL_CARBA-producing Enterobacterales

Nearly all unique (per patient, species and sequence type) ESBL_CARBA isolates (n=574) from notified cases (n=468) in 2025 have been characterised using whole genome sequencing (WGS). The most common carbapenemase-producing Enterobacterales was E. coli, accounting for 70% of all cases, followed by K. pneumoniae (25%). During 2025, the number of cases with clinical infection and carriers with carbapenemase-producing E. coli increased while both cases with clinical infection and carriers with carbapenemase-producing K. pneumoniae decreased or remained stable (Figure 3.10). Genes encoding for carbapenem resistance have also been detected in several other species of Enterobacterales. Multiple species, resistance genes and/or sequence types were found in several cases. The most abundant carbapenemase genes were variants of bla_NDM and bla_OXA-48-like. In addition to these genes, bla_KPC, bla_VIM, bla_IMP, bla_IMI and bla_GES were also detected, but to a lesser extent (Figure 3.11). The most frequent sequence type for K. pneumoniae was ST147, followed by ST307 and ST16. For E. coli, ST410 was most abundant, followed by ST38 and ST13730. Apart from the genotypic analysis, isolates from notified cases in 2025 were tested for antibiotic susceptibility using broth microdilution (BMD) and disk diffusion. The phenotypic resistance shows a high degree of carbapenem resistance in metallobeta-lactamase (MBL)-producing isolates. However, in bla_OXA-48-producing E. coli, meropenem and imipenem resistance is low. This contrasts with K. pneumoniae, where meropenem and imipenem resistance is higher and close to 50% of the isolates are resistant. For the newly introduced antibiotic aztreonam-avibactam, the levels of resistance is low independent of species and carbapenemase type (Figure 3.12).

Clusters and outbreaks

A total of 75 clusters or pairwise linked cases of ESBL_CARBA were identified in 2025 (2-21 cases per cluster), confirmed by SNP analysis. Of the 75 clusters, 28 clusters had at least one case prior to 2025. Forty-six clusters of ESBL_CARBA-producing Enterobacterales were caused by E. coli, 23 by K. pneumoniae, three by Enterobacter species, two by Citrobacter freundii and one by Klebsiella variicola. For 29 clusters, one or more of the cases were reported as a healthcare-related infection within Sweden in 2025. K. pneumoniae ST147/ST307 and E. coli ST648/ST410 were the most common ST-types and occurred in five and six clusters each, respectively. The most common form of carbapenemase among clusters in 2025 was bla_OXA-244 (n=19) and bla_NDM-5 (n=17) for E. coli and bla_OXA-48 (n=5) and bla_NDM-1 + bla_OXA-48 (n=4) for K. pneumoniae.

Comments

In summary, the increase in incidence of cases with ESBL_CARBA in 2025 was particularly driven by domestic cases and among cases with clinical infections or carriers of E. coli with ESBL_CARBA. The number of clusters reported as healthcare-related increased from 16 to 29 between 2023 and 2025.

Figure

Figure 3.9. The incidence (cases/100 000 inhabitants) of cases with ESBL_CARBA producing Enterobacterales in relation to type of infection, year 2016-2025.

Data

Figure

Figure 3.10. Number of cases with clinical infection and carriers with carbapenemase-producing E. coli and K. pneumoniae, year 2016-2025.

Data

Figure

Figure 3.11. Number of isolates and enzyme types of ESBL_CARBA in Enterobacterales in Sweden 2021-2025.

Data

Figure

Figure 3.12. Antimicrobial resistance among ESBL_CARBA-producing Escherichia coli (A) and Klebsiella pneumoniae species complex (B) isolates from notified cases in 2025, stratified by carbapenemase type: NDM (blue; n = 142(A)/38(B)), OXA-48-like (orange; n = 171(A)/37(B)) and KPC (green; n = 17(B)). Isolates with multiple carbapenemases were excluded. Only the first isolate per patient, species, sequence type and year was included; for clustered cases, only the first isolate per cluster was included. Resistance was defined according to EUCAST breakpoint table 16.0 for meropenem (non-meningitis indications), amikacin, gentamicin, tobramycin, fosfomycin (UTI) and nitrofurantoin (uncomplicated UTI). a) Not tested for K. pneumoniae.

Additional Figure - blaOXA-48-like

Additional Figure - blaNDM

Data

3.3.4 Escherichia coli, from blood and urine cultures

For invasive isolates, resistance is stable over the years. Resistance to ciprofloxacin is still high, and is now at approximately 15% and 12% for blood and urine isolates, respectively (Table 3.4, Figure 3.13 and Figure 3.15). Resistance to commonly prescribed oral antibiotics for treatment of urinary tract infections (UTI) caused by E. coli is slowly increasing and cefadroxil resistance (ESBL) is now 8.2% (Figure 3.15).The resistance to carbapenems remains very low overall.

The age and gender distributions among patients with E. coli isolated from urine reflects the expected occurrence of UTI in the different groups. The high level of ciprofloxacin resistance must be considered when choosing empirical treatment for febrile UTI for men in all age-groups (Figure 3.16). Figure 3.17 illustrates that cefotaxime-resistant isolates (ESBL) often display resistance to multiple additional antibiotic classes.

Figure

Figure 3.13. Antibiotic resistance in E. coli isolated from blood during the years 2016-2025.

Data

Figure

Figure 3.14. Antibiotic resistance among cefotaxime-resistant E. coli and K. pneumoniae (ESBL) isolated from blood in 2025.

Data

Figure

Figure 3.15. Antibiotic resistance in E. coli isolates from urine during the years 2016-2025. The numbers of AST isolates for all years and antibiotics ranges from 103 223 to 227 259.

Data

Figure

Figure 3.16. Antibiotic resistance in E. coli from urine in women and men divided in age groups during 2025.

Data

Table

Table 3.4. Proportion (%) of antibiotic resistant E. coli from blood or urine 2025.

Antibiotic	Blood isolates, % R (n = 10 576)	Urine, % R (n =220 589)
Ampicillin	–	29
Cefadroxil	–	8.2
Cefotaxime	9	–
Ceftazidime	8.1	–
Ciprofloxacin	15	12
Gentamicin	5.9	–
Tobramycin	4.6	–
Mecillinam	–	3.9
Meropenem	0	–
Nitrofurantoin	–	1.3
Piperacillin-tazobactam	5.5	–
Trimethoprim	–	20
Trimethoprim-sulphamethoxazole	21	–

Data

3.3.5 Klebsiella pneumoniae, from blood and urine cultures

For invasive isolates, the resistance levels have slowly increased over a ten-year period but the carbapenem resistance remains low. The resistance to cefotaxime was 11% (Table 3.5 and Figure 3.17). Resistance to commonly prescribed oral antibiotics for treatment of urinary tract infections caused by K. pneumoniae has gradually increased during the last years with the exception of mecillinam (Figure 3.18). Cefadroxil resistance, which can be used as an indicator for ESBL production, was 8.5%. Similar to in E. coli, the high levels of resistance to ciprofloxacin, 12%, must be taken into account when choosing empiric treatment for febrile UTI.

Figure

Figure 3.17. Antibiotic resistance in K. pneumoniae isolated from blood during the years 2016-2025.

Data

Figure

Figure 3.18. Antibiotic resistance in K. pneumoniae isolates from urine during the years 2016-2025. The numbers of AST isolates for all years and antibiotics ranges from 9 901 to 29 294.

Data

Table

Table 3.5. Proportion (%) of antibiotic resistant K. pneumoniae from blood or urine 2025.

Antibiotic	Blood isolates, % R (n = 2 039)	Urine isolates, % R (n =29 294)
Cefadroxil	–	8.5
Cefotaxime	11	–
Ceftazidime	11	–
Ciprofloxacin	15	12
Gentamicin	3.4	–
Tobramycin	0.4	–
Mecillinam	–	8.1
Meropenem	0.4	–
Piperacillin-tazobactam	13	–
Trimethoprim	–	21
Trimethoprim-sulphamethoxazole	15	–

Data

3.4 Staphylococcus aureus including MRSA

3.4.1 Mandatory reporting of methicillin-resistant Staphylococcus aureus

Results

• Number of reported cases: 4 147 (previous year 3 937), relative change +5%
• Number of bloodstream infections: 131 (previous year 123)

Trends

In 2025, the incidence of MRSA was 39 cases per 100 000 inhabitants, compared to 37 cases per 100 000 inhabitants in 2024 (Figure 3.19). The number of cases reported with clinical infections was 2 303 (56%), while 1 703 cases (41%) were listed as carriers.

There was almost equal distribution between women and men, with a median age of 36 for all cases. Among the domestic MRSA cases (n=2 614, 63%), children below one year of age (n=211, 215 cases/100 000 inhabitants) had the highest incidence, followed by the elderly, 85 years or older (n=237, 78 cases/100 000 inhabitants). The high incidence of MRSA among the young children is likely due to screening practices at neonatal- and maternal care units in combination with contact tracing around new cases.

Community-acquired infections continue to be the most prominent route of acquiring MRSA. Among MRSA cases acquired in Sweden, 25% (n=655) were reported as acquired from family/household contacts and 23% as community-acquired (n=598). The proportion of domestic cases with MRSA acquired in hospital as well as healthcare/care outside hospital was 5% and 8% respectively (n=123 and n=213), which is nearly the same as in previous years. More than a third (n=1 025) of domestic cases lacked information on the route of transmission.

3.4.2 Microbiological surveillance programme, MRSA

Epidemiological typing of MRSA includes species identification, mecA/C and PVL detection, spa-typing, sequence typing (MLST) and genetic relatedness analysis, based on whole genome sequencing. The overall analyses for the national surveillance program 2025 are delayed. Below are preliminary results based on those reported to Sminet and from the analyses performed at the Public Health Agency so far. Spa-type (n=1 483) or sequence type (ST, n=1 702) was reported to Sminet for 3 134 cases (76%). At the Public Health Agency, spa-typing was performed for about 450 isolates in addition to those included in the national microbiological surveillance programe. For a few cases, both spa-type and sequence type were reported. Over the past five years, the same 13 spa-types have consistently been among the top ten most common each year. These 13 types constituted 56% of all typed clinical isolates in 2025. While the ranking of the most common spa-types somewhat varied over time, t304 has been the most prevalent every year for the past seven years. Additionally, the proportion of PVL-positive isolates was higher in clinical infection than in carriers. Among whole-genome sequenced isolates from clinical cases with ST reported to Sminet (n=1 002), the most common type was ST22 (14%, n=372), followed by ST8 and ST6.

Clusters and outbreaks

In 2025, the Public Health Agency sequenced 100 isolates for regions as part of outbreak investigations and/or within the national microbial surveillance programme for children in neonatal care. Of these, 69 were part of 22 distinct clusters, each containing 2–8 isolates. The remaining 31 isolates showed no genetic relationship to any previously sequenced isolate at the Public Health Agency. Among the 37 isolates from neonatal units, 17 were not genetically related to any other sequenced isolate.

Comments

In summary, the incidence of MRSA increased in 2025, surpassing pre-pandemic levels from the three prior years. The increase was most pronounced in domestically acquired cases and in cases with clinical infections. Additionally, the number of cases with MRSA in bloodstream infections continued to increase.

Figure

Figure 3.19. The incidence (cases/100 000 inhabitants) of cases with MRSA in relation to type of infection, year 2016-2025.

Data

3.4.3 Staphylococcus aureus from blood and skin and soft tissue cultures

The proportion of MRSA from blood and in skin and soft tissue infections is 2.4% and 2.9% respectively (Table 3.6, Figure 3.20 and Figure 3.21). Susceptibility testing to vancomycin is not routinely performed on cefoxitin-susceptible S. aureus and in 2025, 239 of 7 177 (3.3%) isolates from blood were tested for vancomycin resistance with no resistance detected.

Figure

Figure 3.20. Antibiotic resistance in S. aureus isolated from blood during the years 2016-2025.

Data

Figure

Figure 3.21. Antibiotic resistance for S. aureus from skin and soft tissue samples 2016-2025.

Data

Table

Table 3.6. Proportion (%) of antibiotic resistant isolates in S. aureus from blood and skin and soft tissue infectionsin 2025. Results for flouroquinolone are based on norfloxacin.

Antibiotic	Blood isolates, % R (n=7 177)	Skin and soft tissue isolates % R (n= 23 375 - 77 040)
Cefoxitin	2.4	2.9
Clindamycin	5.7	6.8
Erythromycin	6	7.3
Gentamicin	4	–
Tobramycin	1.5	–
Flouroquinolone	3.8	–
Fusidic acid	–	2.7
Linezolid	0.1	–
Rifampicin	0.9	–
Trimetoprim-sulphamethoxazole	0.3	0.2

Data

3.5 Enterococcus faecalis and Enterococcus faecium including VRE

3.5.1 Mandatory reporting of vancomycin-resistant enterococci

Results

• Total number of reported cases: 516 (previous year: 390), relative change +32%.
• Number of reported cases of E. faecium with vancomycin resistance: 502 (previous year: 372), relative change +35%
• Number of reported cases of E. faecalis with vancomycin resistance: 14 (previous year: 18)
• There were eight cases infected with both E. faecium and E. faecalis
• Number of bloodstream infections: 10 (previous year: 6)

Trends

In 2025, the incidence of VRE increased to 4.9 cases per 100 000 inhabitants from 3.7 cases per 100 000 inhabitants in 2024. Eighteen of the 21 regions reported cases of VRE in 2025. Of these cases, 77% (n=395) were healthcare-related. The majority of the isolates (n=449, 87%) were from faecal, rectal and perineal samples, while only 7% were from urine, abscess or wound samples (Figure 3.22). Ten invasive VRE infections were reported in 2025. The majority of cases (n=398, 77%) were reported as acquired in Sweden. Of these, 50% were identified through contact tracing and 34% through screening. Among cases acquired abroad (n=104), most were detected through screening (81%). The median age for VRE cases was 71 (range: 0–95+ years) and VRE remains most common among men (61%). In 2025, 502 cases of E. faecium and 14 cases of E. faecalis were reported. The vanA genotype was most common among E. faecium (n=441) (Figure 3.23). In some cases, multiple genotypes of VRE were detected in the same patient. Thus, a few more isolates than cases were epidemiologically typed.

3.5.2 Microbiological surveillance programme, VRE

Whole genome sequencing (WGS) with single nucleotide polymorphism (SNP)-based analysis and multilocus sequence typing (MLST) are used for epidemiological typing of VRE. The national VRE cluster nomenclature is as follows: species (Efm = E. faecium, Efs = E. faecalis) followed by van-gene (A or B), year of detection and a consecutive number for each type found each year, e.g. SE-EfmB-2503. Isolates with no relation to other VRE isolates in the national database are denoted as unique (EfmA unique). In 2025, there were seven large hospital-related outbreaks, each involving 10-80 cases (Figure 3.24). Of these, three outbreaks (SE-EfmA-2404, SE-EfmB-2408 and SE-EfmA-2424) were identified in 2024 and continued to spread in 2025. Additionally, 29 smaller clusters (each with 2-5 cases) were reported in 2025, all E. faecium.

Among the ten invasive cases, nine cases were caused by E. faecium with vanA (belonging to the outbreak strains SE-EfmA-2404, SE-EfmA-2424, SE-EfmA-2502, SE-EfmA-2503, SE-EfmA-2516 and two unique isolates) and one case was E. faecium with vanB (SE-EfmB-2510). During the year, vancomycin-variable enterococci (VVE) were detected in two clusters: SE-EfmA-2502 (ST117) and SE-EfmA-2503 (ST1421). The SE-EfmA-2503 cluster included five cases, all of which were VVE, while SE-EfmA-2502 comprised 31 cases, 10 of which were VVE. Additionally, a single VVE isolate was identified in cluster SE-EfmA-2424 (ST80), which otherwise contained vancomycin-resistant isolates. VVE classification was based on laboratory reports indicating phenotypic susceptibility to vancomycin despite the presence of the vanA gene. Genes and/or mutations associated with linezolid resistance were detected in eight isolates.

Comments

In summary, the number of VRE cases increased by 32% in 2025. This increase was primarily driven by multiple outbreaks in hospitals. This highlights the importance of preventing VRE transmission in healthcare settings. Epidemiological typing provides a critical tool for monitoring and investigating VRE spread. Culture and typing results are often required to initiate and justify the extensive measures required to control VRE outbreaks.

Figure

Figure 3.22. The incidence (cases/100 000 inhabitants) of VRE in relation to type of infection, year 2016-2025.

Data

Figure

Figure 3.23. Number of VRE cases and their corresponding van-type, year 2016-2025.

Data

Figure

Figure 3.24. Number of VRE cases within the seven largest hospital-related outbreaks in 2025 and their respective sequence type.

Data

3.6 Enterococcus faecalis and Enterococcus faecium, from blood cultures

Results

The vancomycin resistance among invasive isolates remains low and was 2.2% for E. faecium and 0.1% for E. faecalis. High-level aminoglycoside resistance (HLAR) has increased since 2023 for E. faecium (Table 3.7, Figure 3.25 and Figure 3.26).

Table

Table 3.7. Proportion (%) of antibiotic resistant E. faecalis and E. faecium from blood 2025.

Antibiotic	Blood isolates E. faecalis, % R (n = 1 542)	Blood isolates E. faecium, % R (n = 1 002)
Ampicillin	0.1	87
Gentamicin (HLAR)	5.7	26
Linezolid	0.3	0.8
Vancomycin	0.0	2.2

Data

Figure

Figure 3.25. Antibiotic resistance in E. faecalis isolated from blood during the years 2016-2025.

Data

Figure

Figure 3.26. Antibiotic resistance in E. facium isolated from blood during the years 2016-2025.

Data

3.7 Streptococcus pneumoniae including PRP

3.7.1 Mandatory reporting of penicillin-resistant Streptococcus pneumoniae

Results

• Number of reported cases: 211 (previous year 148), relative change 43%
• Number of bloodstream infections: 13 (previous year 12)

Trends

In 2025, the incidence of PRP increased to 2.0 cases per 100 000 inhabitants from 1.4 cases per 100 000 inhabitants in 2024. Among reported cases, 127 (60%) were clinical infections and 27 (13%) were carriers (Figure 3.27). Most isolates were from nasopharynx samples (n=93, 44%), while 36% (n=75) came from sputum or bronchoalveolar lavage samples. The majority of cases (n=130, 62%) were acquired domestically, while 8% were acquired abroad; for the remaining 30%, no country of acquisition was specified. The median age for PRP cases was 56 years (range: 0–94 years) and PRP remains most common among men (58%). The highest incidence was observed in the age group 70–79 years (n=41, incidence 4.1) followed by children in the age group 1–4 years (n=15, incidence 3.5). In 2025, the incidence increased primarily among individuals over 30 years, while it decreased among children under five years.

3.7.2 Microbiological surveillance programme, S. pneumoniae

The Public Health Agency collects all PRP isolates for serotyping as part of the national microbiological surveillance programme. This enables monitoring and evaluating the effectiveness of vaccination against pneumococcal disease, as well as identifying the spread of antibiotic-resistant clones. Since autumn 2023, the 15-valent conjugate vaccine (PCV15) has been used in the childhood vaccination programme, replacing the 10-valent vaccine (PCV10). In 2025, isolates from 195 of the 211 reported cases (92%) were sent to the Agency for serotyping within the national microbiological surveillance programme. Of these isolates, 40% (n=77) belonged to serotypes included in PCV15, Figure 3.28. The corresponding figures for 2024 and 2023 were 35% and 42%, respectively. In 2025, serotype 19F (n=28) was the most common, followed by 19A (n=24), 11A (n=20) and 9N (n=19). Seventeen cases were caused by non-typeable PRP (NT; without capsule). Among the typed isolates from children under five years (n=15), serotype 11A (n=3) was the most common, followed by 19A (n=2). Among the 13 invasive cases, five were caused by serotype 19A, which is covered by PCV15. Notably, none of these serotype 19A cases occurred in children under 10 years. The remaining eight cases were caused by serotypes not included in the PCV15: 9A (n=3), 6C (n=1), 9N (n=1), 11A (n=1), 23B (n=1) and 29 (n=1).

Sine 2025, EUCAST introduced new breakpoints for benzylpenicillin for pneumococci (for indications other than meningitis). According to the new breakpoints, pneumococcal strains with MIC >1 mg/L are classified as penicillin-resistant pneumococci (PRP), and are notifiable under the Infection Control Act. The susceptibility testing recommendation was also updated: laboratories are now encouraged to use disc diffusion (SIR) instead of MIC determination for benzylpenicillin.

The Public Health Agency collects all pneumococcal isolates with oxacillin 1 µg < 9 mm (according to disc diffusion) for serotyping. In 2025, 254 isolates with reduced susceptibility to penicillin were collected (including the 211 isolates from cases of PRP). The serotype distribution was, in descending order: 19F (11%), NT (11%), 19A (10%), 11A (9%), 35B (7%). 9N (6%), 23B (5%), 15A (5%), 23A (4%), 6C and 3 (3%).

Clusters and outbreaks

No PRP clusters were identified in 2025.

Comments

In summary, the number of PRP cases continued to increase in 2025. However, the number of invasive cases remained stable. Over the past decade, the PRP incidence has risen in Sweden. Changes in diagnostics may have contributed to this trend.

Figure

Figure 3.27. The incidence (cases/100 000 inhabitants) of PRP in relation to type of infection, year 2016-2025.

Data

Figure

Figure 3.28. Distribution of serotypes among PRP cases, year 2022–2025. PCV10 includes serotypes 6B, 9V, 14, 19F, and 23F, while PCV15 also includes 3, 6A, and 19A.

Data

3.7.3 S. pneumoniae, from blood

Among invasive infections, the proportion of benzylpenicillin non-susceptible isolates was 8.0% in 2025 (Figure 3.29).

Figure

Figure 3.29. Antibiotic resistance in S. pneumoniae isolated from blood during the years 2016-2025. Penicillin V resistance is based on susceptibility testing using oxacillin.

Data

3.8 Haemophilus influenzae

3.8.1 Haemophilus influenzae, from blood and nasopharynx cultures

• Number of mandatory reported cases of invasive H. influenzae: 279

Comments

Invasive isolates of H. influenzae are notifiable according to the Communicable Disease Act regardless of antibiotic resistance. Cefotaxime resistance among invasive isolates remains low (Figure 3.33 and Table 3.8). Among respiratory isolates, resistance levels to penicillin, ampicillin/amoxicillin, trimethoprim-sulphamethoxazole and cefotaxime increased during 2025 (Figure 3.31).

Figure

Figure 3.30. Antibiotic resistance in H. influenzae isolated from blood during the years 2016-2025.

Data

Figure

Figure 3.31. Antibiotic resistance in H. influenzae isolated from nasopharynx during the years 2016-2025

Data

Table

Table 3.8. Proportion (%) of antibiotic resistant H. influenzae from blood or nasopharynx 2025.

Antibiotic	Blood isolates, % R (n = 240)	Nasopharynx isolates, % R (n =11 496)
Ampicillin/Amoxicillin	28	38
Cefotaxime	2.2	3.6
Fluoroquinolone	4.6	2.2
Screen betalactam resistance	36	46
Tetracycline	1.8	0.4
Trimethoprim-sulphamethoxazole	23	32

Data

3.9 Pseudomonas aeruginosa

Resistance levels are stable for most antibiotics in both blood isolates and non-respiratory isolates (Table 3.9, Figure 3.32 and Figure 3.33). Resistance to ceftazidime is most often due to efflux pumps and porin loss, not ESBL production. Tobramycin has replaced gentamicin as the recommended aminoglycoside. Colistin resistance is occasionally seen in P. aeruginosa and is mainly tested in multiresistant isolates, most of which have a link to health care abroad.

3.9.1 Microbiological surveillance programme, Pseudomonas spp.

In total, 56 unique (per patient, year, species and sequence type) Pseudomonas spp. isolates were analysed in 2025, of which 15 belonged to the microbiological surveillance programme for ESBL_CARBA-producing Pseudomonas spp. Eight of these isolates carried a bla_NDM-gene, three bla_NDM, two bla_VIM and two bla_IMP. Three clusters were active during 2025, with four patients in the two largest clusters (bla_NDM, bla_GES) and two patients in the remaining cluster (bla_NDM).

Figure

Figure 3.32. Antibiotic resistance in P. aeruginosa isolated from blood during the years 2016-2025.

Data

Figure

Figure 3.33. Antibiotic resistance in P. aeruginosa from non-respiratory isolates 2016-2025. The numbers of AST isolates for all years and antibiotics ranges from 3 515 to 18 832.

Data

Table

Table 3.9. Proportion (%) of antibiotic resistant P. aeruginosa isolated from blood and non-respiratory isolates 2025.

Antibiotic	Blood isolates, % R (n = 816)	Non-respiratory isolates, % R (n =16 815)
Ceftazidime	7.1	5.3
Ciprofloxacin	7.7	8.7
Tobramycin	0.9	6.3
Meropenem	4.7	2.8
Piperacillin-tazobactam	8.6	7.7

Data

3.10 Acinetobacter spp.

3.10.1 Acinetobacter spp., from blood cultures

In 2025, 123 isolates of Acinetobacter spp. from blood were reported to Svebar. Carbapenem resistance was observed in 3.3% of the isolates (Figure 3.34). Bloodstream infections caused by Acinetobacter spp. are still rare in Sweden compared to other countries in Europe, where multiresistant Acinetobacter spp. is a problematic pathogen in hospitals. Colistin resistance is occasionally seen in Acinetobacter and is mainly tested in multiresistant isolates, most of which have a link to health care abroad.

3.10.2 Microbiological surveillance programme, Acinetobacter spp.

In total, 37 unique (per patient, year, species and sequence type) isolates were received in 2025 within the microbiological surveillance programme for Acinetobacter spp. with reduced susceptibility to meropenem (I+R). This is a decrease compared to what was seen in 2024 (n=54), but similar to what was observed in 2023 (n=42). Of the 37 isolates, 28 carried species-specific bla_OXA-genes (23, 24 or 58-like), eight harboured a combination of bla_OXA (23, 24 or 58-like) and bla_NDM and in one isolate, no carbapenemase gene was detected. Four clusters were active during 2025, with the number of unique isolates ranging from 2-6.

Figure

Figure 3.34. Antibiotic resistance in Acinetobacter spp. isolated from blood during year 2016-2025.

Data

3.11 Streptococcus pyogenes

3.11.1 Streptococcus pyogenes, from blood cultures

Results

• Number of mandatory reported cases of invasive S. pyogenes: 750

Comments

Invasive cases of S. pyogenes are notifiable according to the Communicable Disease Act. In 2025, the incidence fell to 7.1 (cases/100 000 inhabitants), down from 12.9 in 2024 (n= 1 367). AST data for 509 isolates were provided by Svebar (Figure 3.35). Since 2023, resistance to clindamycin and erythromycin has stabilised at prepandemic levels and are now 4.5% and 6.3%, respectively. Some laboratories did not test susceptibility to trimethoprim-sulphamethoxazole and tetracycline. The variation in resistance during 2021 to 2022 should be viewed cautiously due to limited number of isolates.

Figure

Figure 3.35. Antibiotic resistance in S. pyogenes (GAS) from bloodstream isolates during the years 2016-2025. The numbers of AST isolates for all years and antibiotics ranges from 139 to 1 006. The exact numbers are given in the attached file.

Data

3.12 Streptococcus agalactiae

3.12.1 Streptococcus agalactiae, from blood cultures

Comments

S. agalactiae is not included in the Communicable Disease Act. It is an important pathogen in the context of pregnancy and childbirth and can cause serious infections among others as well, such as elderly with predisposing disease. Resistance to erythromycin and clindamycin is now 18% and 16%, respectively (Figure 3.36).

Figure

Figure 3.36. Antibiotic resistance in S. agalactiae (GBS) from blood during the years 2016-2025. The numbers of AST isolates for all years and antibiotics ranges from 256 to 685. The exact numbers are given in the attached file.

Data

3.13 Shigella species

3.13.1 Mandatory reporting of Shigella

Results

• Total number of reported cases: 829 (previous year: 789)
• Number of bloodstream infections: 0 (previous year: 0)

Comments

The number of reported Shigella cases in 2025 remained stable compared to 2024. However, the incidence of Shigella infection has shown a clear upward trend over the past decade, both among cases acquired domestically and among cases acquired abroad. In 2025, 79% of the cases were reported as having been acquired abroad, while 16% were reported as having been acquired in Sweden. The number of reported cases increased before 2020, partly due to changes in diagnostic practices, with nucleic acid amplification tests becoming increasingly widely used. In 2025, 66 cases with Shigella were also reported to carry ESBL-producing Enterobacterales. Of the 47 cases with a known ESBL type, all were identified as ESBL_A. No cases with Shigella carrying ESBL_CARBA were reported during 2025.

3.13.2 Shigella spp., from faecal samples

In 2025, 203 isolates of Shigella in feacal samples were reported in Svebar and AST results were available for 194 isolates. The majority of isolates with AST were S. sonnei and S. flexneri, with 53% and 24% of the isolates, respectively. None of the isolates were carbapenem resistant (Figure 3.37). The number of isolates with an AST available for analysis was low. Hence, results should be interpreted with caution. The increase in cefotaxime resistance indicates a higher presence of ESBL among the tested isolates.

Figure

Figure 3.37. Antibiotic resistance in Shigella spp. from faecal samples 2021-2025. The numbers of AST isolates for all years and antibiotics ranges from 40 to 227.

Data

3.13.3 Microbiological surveillance programme, Shigella sonnei and Shigella spp.

In total, 20 isolates were received in 2025 within the microbiological surveillance programme for Shigella sonnei and Shigella spp. with resistance to ciprofloxacin and cefotaxime and/or ceftazidime.

Whole genome sequencing and subsequent SNP-analysis confirmed that six of the 20 received isolates belonged to a cluster with a total of 34 isolates. The cluster is genetically related to a multidrug-resistant and internationally spread S. sonnei carrying a bla_CTX-M-15 gene, reported by the Netherlands on June 2023 and the United Kingdom on December 2023, mainly affecting men who have sex with men (European Centre for Disease Prevention and Control (ECDC) 2025).

3.14 Mycobacterium tuberculosis

3.14.1 Mycobacterium tuberculosis, mandatory reporting

During 2025, a total of 306 cases of tuberculosis (TB) were reported, compared to 315 cases during 2024. The number and proportion of culture-confirmed cases was 254 (83%) compared to 254 (81%) in 2024. Mycobacterium bovis was identified in two cases, Mycobacterium africanum in two cases and Mycobacterium tuberculosis in 250 cases (Figure 3.38). The proportion of Mycobacterium tuberculosis cases diagnosed with MDR-TB was 2.8% (7/250) compared to 1.6% (4/248) in 2024. One of the MDR-cases was classified as pre-XDR-TB and one as XDR-TB (additional resistance to fluoroquinolones in both and the XDR-TB was also resistant to bedaquiline).

Isolates of M. tuberculosis resistant to at least one of the four first line drugs (isoniazid, rifampicin, ethambutol or pyrazinamide) or fluoroquinolones were identified in 29 patients, corresponding to 12% of the 250 patients with culture-confirmed M. tuberculosis, (Figure 3.39). As always, the most common observed resistance was against isoniazid.

Of 47 people with tuberculosis born in Sweden, 41 had a culture-confirmed diagnosis with M. tuberculosis, one with an isoniazid resistant strain, one with a rifampicin resistant strain and two cases with MDR-TB. Of all the TB cases reported in Sweden 2025, 85% were born in another country. In total, 209 in this group had a culture-confirmed infection with M. tuberculosis and 25 (12%) had some kind of resistance of which five had MDR-TB.

Genetic typing of TB isolates has been performed in Sweden since the late 1990’s. This is done to identify clusters of cases as clustering indicates possible recent transmission and helps to identify missed opportunities of infection control. Of all the cases, 15% (47/306) were reported as acquired in Sweden and of 254 (including M. bovis and M. africanum) cases analysed with whole genome sequencing, 80% were unique isolates not belonging to any cluster.

The number of reported TB cases in Sweden continued to decrease in 2025 and 306 cases of TB is the lowest case number ever reported since surveillance started in 1940.

Figure

Figure 3.38. The number of culture confirmed M. tuberculosis in Sweden cases in Sweden 2016-2025.

Data

Figure

Figure 3.39. Percentage of resistant M. tuberculosis isolates based on the total number of culture confirmed cases, 2016-2025.

Data

3.15 Neisseria gonorrhoeae

3.15.1 Neisseria gonorrhoeae, mandatory reporting

Gonorrhoea is a notifiable infection and in 2025, 4 268 cases (40.2 cases per 100 000 inhabitants) of gonococcal infections were reported to the Public Health Agency of Sweden. This represents a relatively stable incidence compared to 2024 (4 365 cases, 41.2 cases per 100 000 inhabitants). As in earlier years, most of the gonorrhoea cases in 2025 were identified in the three largest counties of Sweden, which comprise the cities Stockholm, Göteborg and Malmö, respectively. Clinical isolates in the present report are described by the National Reference Laboratory for Sexually Transmitted Infections (an external body of the Public Health Agency of Sweden), Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, Örebro; Department of Clinical Microbiology, Karolinska University Hospital, Huddinge; Department of Clinical Microbiology, Umeå University Hospital, Umeå; and Clinical Microbiology, Infection Prevention and Control, Office for Medical Services, Lund, Sweden. In 2025, the antimicrobial susceptibility of 2 540 clinical N. gonorrhoeae isolates (one different per infection episode) is presented.

Antimicrobial susceptibility testing was performed according to standardised and quality-assured methodology using Etest for MIC determination of ceftriaxone, cefixime, azithromycin, spectinomycin, ciprofloxacin and tetracycline. The current clinical resistance breakpoints from the European Committee on Antimicrobial Susceptibility Testing were used for ceftriaxone, cefixime, ciprofloxacin, spectinomycin and tetracycline. EUCAST does not state any clinical resistance breakpoint for azithromycin and in this report the EUCAST Epidemiological Cut-Off (ECOFF), distinguishing isolates with azithromycin resistance mechanisms, is instead used for azithromycin.

In short, the level of resistance to ciprofloxacin remains very high (69% in 2025). The proportion of isolates above the azithromycin ECOFF (MIC>1 mg/L) was 26%, which represents an increase since 2024 (22%). The resistance to cefixime remained low, but it had doubled since 2024 (increased from 0.4% to 0.7%). For the fourth consecutive year since 2014, ceftriaxone-resistant cases (n=9) were identified in Sweden, and the resistance had increased from 0.1% in 2024 to 0.4% in 2025, which is a major concern. Ceftriaxone is the last remaining option for empirical antimicrobial monotherapy of gonorrhoea and it is a major concern if ceftriaxone-resistant strains start to spread widely. For example, this has been observed in some Asian countries, such as Cambodia, China, Japan and Vietnam. No gonococcal isolates resistant to spectinomycin have yet been detected in Sweden. However, the availability of spectinomycin can be limited (in Sweden as in most countries globally), and it is not suitable as monotherapy for pharyngeal gonorrhoea. Finally, the National Reference Laboratory for Sexually Transmitted Infections in Örebro also examined the susceptibility to tetracycline in 2025. This testing was initiated due to the interest of using doxycycline post-exposure prophylaxis (Doxy-PEP) against bacterial sexually transmitted infections (syphilis, chlamydia and gonorrhoea). The level of resistance to tetracycline was 54% (similar to 57% in 2024), which indicates that it is unlikely that Doxy-PEP will significantly reduce the incidence of gonorrhoea cases in Sweden (Figure 3.40).

Figure

Figure 3.40. Antibiotic resistance rates (%) in Swedish clinical Neisseria gonorrhoeae isolates, 2016–2025, highlighting azithromycin, ciprofloxacin and tetracycline. For cefixime, spectinomycin and tetracycline, 2 196, 2 197 and 600 N. gonorrhoeae isolates were tested in 2025, respectively.

Data

3.16 Neisseria meningitidis

3.16.1 Neisseria meningitidis, mandatory reporting

Invasive meningococcal disease (IMD) is a notifiable disease in Sweden. Following a sharp decline during the COVID-19 pandemic, the incidence of IMD has increased, with 42 cases reported in 2025. This corresponds to an incidence of 0.4 cases per 100 000 inhabitants, approaching the levels observed in the years preceding the pandemic. Clinical samples (one per patient) were available from all 42 cases, including isolates from blood, cerebrospinal fluid and joint fluid in 40 of the cases. These samples were characterised at the National Reference Laboratory for Neisseria meningitidis, an external unit of the Public Health Agency of Sweden located within the Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital. In total, 40 cases were culture-confirmed and the remaining two were confirmed by PCR only.

Antimicrobial susceptibility testing was performed on all culture-confirmed isolates (n=40) using standardised and quality-assured methodology. Minimum inhibitory concentrations (MICs) of benzylpenicillin, cefotaxime, meropenem, chloramphenicol, ciprofloxacin and rifampicin were determined using Etest. Beta-lactamase production was assessed using nitrocefin solution.

All isolates (100%) were susceptible to benzylpenicillin (MIC range: 0.032–0.25 mg/L), cefotaxime (<0.002–0.032 mg/L), meropenem (0.004–0.064 mg/L), chloramphenicol (0.125–2 mg/L), ciprofloxacin (0.002–0.008 mg/L) and rifampicin (0.002–0.064 mg/L). No beta-lactamase production was detected in any of the 2025 isolates. To date, no beta-lactamase-producing N. meningitidis isolate has ever been identified in Sweden.

3.17 Clostridioides difficile

Incidence of Clostridioides difficile infections

In 2025, 6 067 new CDI cases were reported, corresponding to an incidence of 60 cases per 100 000 inhabitants (total number and incidence corrected for missing data from one laboratory). A case is considered new if at least eight weeks have elapsed since the previous positive test, otherwise it is counted as an ongoing illness episode or recurrence. The incidence is similar to the average incidence observed in the last three years (incidence 61). As in previous years, there are major differences between regions (range 26-119 cases per 100 000 inhabitants; Figure 3.41).

Figure

Figure 3.41. The incidence of new cases with C. difficile (cases/ 100 000 inhabitants) by region in 2025 and average for the years 2022-2024. The regions are ranked from highest to lowest incidence in 2025.

Data

3.18 Candidozyma auris

3.18.1 Microbiological surveillance programme, Candidozyma auris

In January of 2025, a new microbiological characterisation programme for Candidozyma auris (formerly Candida auris) was introduced. C. auris has in recent years gained attention as a globally spread, multidrug-resistant yeast that causes severe healthcare-associated infections. In Sweden, C. auris has only occurred in sporadic cases among individuals who previously received hospital care abroad. In the previous 5 years, from 2020 to 2024, a total seven cases of C. auris have been reported in Sweden according to Svebar. Isolates from five patients, two women and three men age 20-77 years, were collected within the programme in 2025 and characterised with species confirmation and antifungal susceptibility results (AFST) at the national reference laboratory for fungi, at Karolinska University Hospital. The AFST results of these are shown in Table 3.10 as resistance patterns. As expected, all isolates show elevated MICs for fluconazole, as the majority of C. auris strains have acquired resistance to the drug. Three isolates also show elevated MICs and resistance to anidulafungin, which is perhaps less expected, as C. auris resistance to echinocandins is less frequently reported (Table 3.10).

Table

Table 3.10. C. auris AST, isolates collected in 2025. SIR interpreted according to EUCAST Breakpoint tables for interpretation of MICs for antifungal agents, version 12.1, 2026. ECOFFS as defined in: EUCAST. Overview of antifungal ECOFFs and clinical breakpoints for yeasts, moulds and dermatophytes using the EUCAST E.Def 7.4, E.Def 9.4 and E.Def 11.0 procedures. Version 6.0, 2025. “IE” indicates that there is insufficient evidence that the species in question is a good target for therapy with the drug. EUCAST ECOFF, Amphotericin B (WT ≤ 2 mg/L) and Anidulafungin (WT ≤0.25 mg/L).

Antimicrobial	Amphotericin B - MIC mg/L	Amphotericin B - SIR	Anidulafungin - MIC mg/L	Anidulafungin - SIR	Flukonazol - MIC mg/L	Itrakonazol - MIC mg/L	Posakonazol - MIC mg/L	Vorikonazol - MIC mg/L
Patient 1	0.5	I	4	R	16	0.06	0.03	0.125
Patient 2	0.5	I	1	R	64	0.125	0.06	0.25
Patient 3	1	I	0.125	S	16	0.03	0.016	0.125
Patient 4	0.5	I	0.5	R	64	0.25	0.125	2
Patient 5	1	I	0.25	S	32	0.03	0.016	0.25

Data

3.19 Campylobacter

3.19.1 Mandatory reporting of Campylobacter

Results

• Total number of reported cases: 5 463 (previous year: 5 440)

Comments

Half of the cases, 51%, reported Sweden as country of infection. The seasonal pattern for domestic cases with campylobacteriosis was as typically seen, with an increase of cases in July and August. The increase in cases was preceded by an observed increase in the proportion of positive samples in broiler flocks. 46% acquired campylobacteriosis abroad. The majority of the imported cases were from Europe (n=1 431) or Asia (n=758). The proportion of domestic and infections acquired abroad was similar to the last previous years, reaching pre-pandemic levels.

3.19.2 Campylobacter jejuni, from faecal samples

Comments

A total of 1 374 Campylobacter species were found in faecal sampling. Almost four-fifths of the isolates were reported as C. jejuni, 14% as C. jejuni/C. coli and the rest were other species. The presence of AST data, and in a sufficient number of isolates, was highest for C. jejuni (34 % of all reported isolates). For C. jejuni, resistance to ciprofloxacin was 56% and 30% for tetracycline in 2025. Resistance to erythromycin was 0.8% (Figure 3.42). The proportion of isolates fully susceptible to erythromycin, ciprofloxacin and tetracycline was 43% and the proportion fully resistant was 0.6% (Figure 3.43). It should be noted that the number of isolates with combined AST is low. Only two fully resistant isolates were reported in 2025.

Figure

Figure 3.42. Antibiotic resistance in Campylobacter jejuni from faecal samples 2016-2025. The numbers of AST isolates for all years and antibiotics ranges from 254 to 816.

Data

Figure

Figure 3.43. Combined susceptibility and resistance to erythromycin, ciprofloxacin and tetracycline in Campylobacter jejuni from faecal samples 2016-2025.

Data

3.20 Salmonella

3.20.1 Mandatory reporting of Salmonella

Infection with Salmonella species are divided into three notifiable diseases in Sweden: infection with Salmonella enterica (S. Typhi and S. Paratyphi excluded), typhoid fever and paratyphoid fever. In addition, cases with Salmonella carrying ESBL or ESBL_CARBA are also notifiable in the mandatory reporting of ESBL-producing Enterobacterales.

Results

• Total number of reported cases with Salmonella enterica: 1 431 (previous year: 1 612)
• Total number of reported cases with typhoid fever: 16 (previous year: 26)
• Total number of reported cases with paratyphoid fever: 24 (previous year: 9)
• Total number of Salmonella carrying ESBL: 16 (previous year: 15)
• Total number of Salmonella carrying ESBL_CARBA: 0 (previous year: 1)

Comments

In 2025, half of the notifiable Salmonella infections were acquired in Sweden and almost half (48%) of the cases acquired salmonellosis abroad. For 2%, information was lacking. There have been five outbreaks with ten or more cases during the year, one of which included more than 100 cases with S. Enteritidis. This outbreak was linked to domestically produced eggs. The second largest outbreak had 48 cases infected with either of four different serotypes (S. Typhimurium, S. Richmond, S. Kinondoni, S. Newport) included. This outbreak was international and linked to alfalfa sprouts. No case was reported with Salmonella carrying ESBL_CARBA.

3.20.2 Salmonella, from blood or faecal and urine samples

A total of 1 790 Salmonella enterica isolates were reported in Svebar, with 73% (n= 1 306) from faecal samples, 18% (n= 318) from blood and 6% (n= 104) from urine. For these sampling materials, approximately half had AST results reported. A comparison for 2025 is presented in Table 3.11.

Since 2021, the number of isolates found in blood with AST results has ranged between 45-152 per year and antibiotic (Figure 3.45). The data may contain duplicates and there is a risk of overestimation of the resistance. Hence, results should be interpreted with caution. The general increase in resistance among faecal and urine isolates seen in 2022 (Figure 3.44) was probably linked to the increase of Salmonella isolates carrying ESBL. This increase then declined in the following years. In 2025, no significant changes were seen in resistance. Almost four-fifths of the Salmonella from faecal and urine samples were fully susceptible to azithromycin, cefotaxime and ciprofloxacin (Table 3.12).

Figure

Figure 3.44. Antibiotic resistance in Salmonella enterica from faecal and urine samples 2016-2025. Results from S. Typhi and S. Paratyphi have been excluded. The numbers of AST isolates for all years and antibiotics ranges from 157 to 875.

Data

Table

Table 3.11. Antibiotic resistance in Salmonella enterica (S. Typhi and S. Paratyphi excluded) isolated from blood or from faeces and urine samples in 2025.

Antibiotic	Blood, % R (n= 45-152)	Faeces/urine, % R (n= 271-517)
Azithromycin	6.7	1.6
Cefotaxime	2	2.9
Ceftazidime	2	2.3
Fluoroquinolone	22	21
Meropenem	0	0
Piperacillin-tazobactam	0	2.8
Trimethoprim-sulphamethoxazole	4.1	4.6

Data

Figure

Figure 3.45. Antibiotic resistance in Salmonella enterica from blood samples 2021-2025. Results from S. Typhi and S. Paratyphi are excluded. The numbers of AST isolates for all years and antibiotics ranges from 45 to 152.

Data

Table

Table 3.12. Combined suceptibility and resistance to azithromycin, cefotaxime and ciprofloxacin in Salmonella enterica from faecal and urine samples 2021-2025. Results from S. Typhi and S. Paratyphi have been excluded.

Sample: Faeces and urine	2021	2022	2023	2024	2025
Number of isolates with combined AST for azithromycin, cefotaxime and ciprofloxacin	267	327	342	311	269
Proportion fully suseptitible to azithromycin, cefotaxime and ciprofloxacin, %	79	73	76	78	78
Proportion fully resistant to azithromycin, cefotaxime and ciprofloxacin, %	0	1.5	0	0	1

Data

Council of the European Union. 2023. Council Recommendation on Stepping up EU Actions to Combat Antimicrobial Resistance in a One Health Approach. Recommendation. https://data.consilium.europa.eu/doc/document/ST-9581-2023-INIT/en/pdf.

European Centre for Disease Prevention and Control (ECDC). 2025. Communicable Disease Threats Report, 29 November - 5 December 2025, Week 49. Weekly Report. https://www.ecdc.europa.eu/en/publications-data/communicable-disease-threats-report-29-november-5-december-2025-week-49.

European Committee on Antimicrobial Susceptibility Testing (EUCAST). 2025. Breakpoint Tables for Interpretation of MICs and Zone Diameters. Version 15.0. https://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/Breakpoint_tables/v_15.0_Breakpoint_Tables.pdf.

Wilson, Edwin Bidwell. 1927. “Probable Inference, the Law of Succession, and Statistical Inference.” Journal of the American Statistical Association 22 (158): 209–12.