Discussion

This study collected 309 priority statements from 103 AMR stakeholders spanning nine professional sectors across four career stages. Using inductive and deductive thematic coding, we identified 12 AMR priority themes and assessed their prominence across sectors and experience levels working in AMR. This study captures what stakeholders think, observe, or experience regarding areas of AMR mitigation perceived to be insufficiently addressed. These perceptions do not directly quantify the magnitude of existing implementation gaps, rather, they reflect the priorities and concerns of professionals working across the AMR landscape. The findings of this study should therefore be interpreted within this context.

Across analysis, antimicrobial stewardship and use and environmental AMR and waste were consistently cited by stakeholders as insufficiently addressed, accounting for 36.7% of total weighted scores. A second tier included IPC/WASH, Surveillance, and R&D. Impact-Effort analysis identified four perceived priority areas as “Quick Wins”: stewardship, IPC/WASH, surveillance, and animal health. No significant association was observed across sector (P = .91) or career stages (P = .13), indicating priorities are widely recognized across disciplines and career stages.

We acknowledge several limitations in this study. First, convenience sampling may have introduced selection bias toward stakeholders engaged in global AMR discourse. We mitigated this by recruiting across multiple sectors and experience levels. Second, free-text responses may introduce interpretative variability during coding. This was addressed using a structured thematic codebook and consensus review. Third, weighting (Top 1 = 3, Top 2 = 2, and Top 3 = 1) may overemphasize rank differences. We addressed this by reporting both weighted and unweighted results. Fourth, sparse cells in experience categories limited Chi-squared reliability; Fisher’s exact test was used instead. Fifth, although English only administration of the survey may have limited participation, we ensured the survey was distributed through multiple international AMR and One Health networks. Additionally, the professional sector categories used in this study were predefined by the research team, and respondents self-selected from nine fixed options. While this approach ensures consistency across responses, it does not capture differences within each broad category. For example, the clinical category may include professionals from different specialties such as infectious disease, surgery, or general practitioners, while the NGO category may include organizations with different roles and priorities. This may limit the interpretation of sector-specific findings and highlights the need for more detailed classifications in future studies. Finally, effort scores in the Impact-Effort analysis were based on informed authors consensus rather than formal Delphi procedures. We ensured scores were informed by existing literature applied using transparent criteria.

Notwithstanding these limitations, this study provides a stakeholder-led assessment of perceived gaps in AMR mitigation efforts using an open-ended question. Combining inductive coding with deductive alignment enhanced validity, while restructuring responses into long format enabled transparent quantification. The integration of weighted ranking and Impact-Effort analysis translated findings into actionable guidance.

The identification of antimicrobial stewardship and use as the most frequently cited perceived gap in AMR mitigation efforts (18.8% of responses, weighted score 119) presents a notable paradox. Despite being a cornerstone of the World Health Organization (WHO) Global Action Plan on AMR, and numerous national and professional guidelines, ^4,17 it surfaced as the most frequently cited perceived gap among stakeholders, pointing to a substantial disconnect between stewardship policy and how respondents experience its implementation on the ground. ^{Reference Raka and Kurti18,Reference Wu, Tannous, Haldane, Grundy and Legido-Quigley19} One respondent noted: “Overuse and misuse of antimicrobials by unqualified persons, including quacks, and lack of supervision by trained professionals, especially in LMICs. Besides, there are no systems in place to check such activities.” Another pointed to diagnostic limitation explaining that: “In many regions, empirical antibiotic use is the default due to a lack of rapid diagnostics and microbiology capacity. This leads to broad-spectrum overuse, driving resistance.”

Our findings suggest that respondents perceived this gap as stemming not from lack of technical feasibility but from insufficient political will and prioritization, inadequate funding, and a failure to adapt interventions to local contexts. These findings corroborate recent qualitative studies, which noted lack of clear political commitment, inadequate funding, and failure to adapt interventions to local context as major barriers to antimicrobial stewardship programs. ^{Reference Livorsi, Drainoni, Reisinger, McMahon, Batalden and Kaboli20} As one respondent observed: “Although AMR is recognized as a global threat by WHO and other UN agencies such as FAO, UNEP, and WOAH, their efforts to create integrated programs that reach all countries and people, especially in low-income countries and their indigenous peoples, are fragmented and inadequate.” The widespread emphasis on stewardship across professional sectors and experience levels underscores global recognition of this issue. Addressing what respondents perceive as this gap requires shifting focus from creating more guidelines to ensuring their implementation. ^{Reference Livorsi, Drainoni, Reisinger, McMahon, Batalden and Kaboli20} In our Impact-Effort Matrix analysis, antimicrobial stewardship and use was classified as a “Quick Win” (Impact score 119, effort 3/5, n = 58 mentions), suggesting that with the right political will and mobilized resources, this strategy can deliver high impact with relatively low to moderate effort.

Environmental AMR and waste was the second most cited perceived gap and the most frequent Top 1 priority ranking, reflecting a growing recognition of environmental transmission pathways. Once confined to specialist research communities, environmental AMR has become a mainstream concern among AMR stakeholders. ^{Reference Sassi, Basher, Kirat, Hasnaoui, Mouradi and Bouras21} This could be due to accumulating evidence that environmental reservoirs and transmission pathways substantially contribute to resistance dissemination. ^{Reference Samreen, Malak and Abulreesh22} One respondent emphasized, “I believe that focusing on antibiotic prescriptions is a mistake; we are overlooking a large part of the problem related to the environment and the plastisphere.” Another noted, “The abuse of antibiotics in farming; for example, most fish farmers tend to use antibiotics for their aquaculture and release these ‘antibiotics heavy laden’ wastewater without any form of pretreatment.”

These perspectives highlight perceived gaps in environmental AMR mitigation efforts including wastewater disposal from healthcare facilities, pharmaceutical manufacturing, and livestock operations, which often contain high concentrations of antimicrobial residues, resistant bacteria strains, and mobile genetic elements encoding resistance. ^{Reference Berendonk, Manaia and Merlin23} Classifying Environmental AMR and waste as a “Major Project” in our Impact-Effort analysis acknowledges the substantial infrastructure investments, regulatory frameworks, and multi-sectoral coordination required for effective intervention. International collaboration including support from the Quadripartite organizations (WHO, WOAH, FAO, UNEP) are essential as environmental AMR is inherently transboundary and no one country can address it alone. ⁵

IPC/WASH, surveillance, and animal health were classified as “Quick Wins”, reflecting perceived implementation gaps by stakeholders despite strong evidence-base and inclusion in global frameworks. ^{4,Reference Tartari, Tomczyk, Twyman, Allegranzi and Pittet24} IPC/WASH received 9.4% of perceived gap mentions with a weighted score of 63 and was notably over-represented among second-tier priorities (16 mentions in the Top 2). This positioning suggests that IPC/WASH is seen by stakeholders as foundational yet complementary to more specialized interventions, a perception that may reflect persistent underestimation of its impact. Available studies and reports demonstrate that comprehensive IPC/WASH programs reduce healthcare-associated infections by 35%–70%, directly preventing the emergence and transmission of resistant bacteria. Every infection prevented eliminates the need for antimicrobial therapy, reducing selection pressure that drives resistance evolution. ^{Reference Tartari, Tomczyk, Twyman, Allegranzi and Pittet24,25} Despite this evidence, IPC implementation remains inadequate globally. A respondent from the Research/Academic sector said: “Our work in low- and middle-income countries shows that while antibiotic use by people has a significant impact on carriage of resistant bacteria in hospitals, this isn’t the case in communities. Multiple studies reveal that community-level transmission factors, broadly associated with sanitation and hygiene, are closely associated with the probability of colonization with drug-resistant bacteria.” Indeed, the WHO Global IPC Survey confirms that fewer than half of countries have established national IPC programmes with dedicated financing, ²⁵ and the emphasis on IPC by clinical professionals (15.0% of clinical priorities) reflects frontline recognition of these persistent gaps. Addressing what respondents identify as persistent IPC gaps requires sustained investment in healthcare workers’ training, and supervision, reliable water, sanitation, and hygiene infrastructure in healthcare facilities, and a supply chain system that ensures consistent availability of essential IPC supplies. The classification of IPC/WASH as a “Quick Win” confirms that high impact is achievable with relatively modest effort.

Awareness and education accounted for 8.4% of stakeholders perceived gap mentions, with a weighted score of 52, placing it near the boundary between Fill-Ins and Quick Wins. Evidence indicates that education yields impact primarily when combined with structural change, decision-support tools, and regulatory enforcement, rather than as a standalone measure. ^{Reference Mitchell, Cooke and Ahorlu26} One respondent captured this tension: “I can say we think we say it enough, but the impact is not there yet. People jump from one antibiotic to the other without thinking twice. A contributing factor is the fact that these antibiotics are readily available and accessible in Africa. I recently moved from Nigeria to Sweden, and I can tell the difference.” The Fill-Ins classification of this theme reflects stakeholders’ recognition that education functions primarily as an enabler of other interventions. ²⁷ Its relatively low implementation cost makes it a valuable addition to comprehensive AMR programmes.

Surveillance, laboratory and data received 9.4% of perceived gap mentions (weighted score 59), reflecting stakeholders perceived challenges in AMR data generation, particularly in low- and middle-income countries (LMICs) where laboratory networks remain fragmented and under-resourced. Broad consensus across all sectors suggests current systems inadequately capture resistance patterns and trends. One respondent observed, “Global AMR strategies still focus mainly on hospitals, yet most antibiotic use and transmission occur in the community.” Although the WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS) has expanded to over 100 countries, substantial gaps in data quality, representativeness, and geographic coverage persist. ¹⁴ The “Quick Win” classification of this theme reflects opportunities to leverage existing infrastructure like tuberculosis and HIV laboratory networks in LMICs for targeted AMR capacity building. As one respondent recommended: “Sewage surveillance of AMR is mandatory in EU now. It should become routine globally, so we can track the epidemic and global sharing of resistance gene alleles.”

Animal health and food system received 8.1% of perceived gap mentions by stakeholders (weighted score: 54). This reflects stakeholders’ recognition that agricultural antimicrobial use, estimated to equal or exceed human use in many countries, drives substantial selection for resistance and environmental contamination. Although the use of antimicrobials as growth-promoting agents has been banned in many high-income countries, the practice continues in numerous LMICs where regulations are limited. ^{Reference Tang, Caffrey and N óbrega28} The “Quick Win” classification of this theme reflects opportunities to engage agricultural sectors through established extension, improved practices, expanded vaccine access, and alternatives to prophylactic antimicrobial use. One respondent who identified cross-sectoral coordination as a central challenge said, “Lack of effective communication and collaboration across sectors - despite awareness of the need for One Health approaches, it’s still challenging to implement these effectively; and to address the different incentives across sectors (economic pressures in agriculture, vs human health care and health care systems, etc.).”

Three themes: access, equity and medicine quality (weighted score 41), financing, infrastructure and health systems (weighted score 21), and policy, governance and regulation (weighted score 17) were classified as “Hard Slogs” in our Impact-Effort analysis owing to their high implementation complexity relative to perceived impact. These represent enabling conditions rather than direct interventions, and their lower emphasis (access: 7.8% of responses) likely reflect stakeholders’ perception that they are broader health system challenges transcending AMR actions. Addressing medicine quality requires strengthened pharmaceutical regulation, supply chain integrity, and enforcement capacity. Similarly, improving equitable access requires health financing reforms, implementation of essential medicines lists, and supply chain strengthening that extend far beyond AMR. The minimal emphasis on financing and health system (3.9% of responses) likely reflects stakeholders’ perception of their status as foundational prerequisites for all health programs. Policy and governance received the second-lowest perceived gap mention (2.6% of responses), yet policy frameworks provide the essential foundation for nearly all AMR interventions. This minimal emphasis by stakeholders reveals potential blind spots, given that effective AMR interventions require policy environments providing legal authority, institutional mandates, and accountability mechanisms. Strategic approaches should embed policy advocacy within implementation, enabling pilot programmes to generate evidence for adoption and scale-up. ^{Reference Park, Kang, Choi and Gwak29}

One Health integration and coordination received the lowest perceived gap prioritization (2.3% of responses, weighted score 9) and, uniquely, zero Top 1 priority ranking, appearing exclusively in Top 2 and Top 3 rankings. This reveals a striking disconnect: while One Health dominates AMR policy discourse, implementation remains siloed and sector specific. Stakeholders seem to view coordination as instrumental infrastructure enabling concrete actions, rather than as a priority. This finding challenges how One Health is communicated and operationalized. Future AMR policies should emphasize concrete interventions with One Health frameworks rather than coordination for its own sake.

For policymakers and funders, the findings of these perceived gaps by AMR stakeholders suggest that resource allocation should emphasize scaling proven interventions (Quick Wins) while supporting long-term investment in complex challenges (Major Projects). Funding mechanisms must balance innovation with adequate support for foundational interventions such as stewardship, IPC, and surveillance as perceived by respondents as inadequately implemented in many settings despite their well-established status as priorities. For practitioners implementing AMR interventions, our findings highlight a recurring concern among respondents: evidence-based interventions developed in high-income settings require substantial contextual adaptation for successful implementation in resource-limited settings. ^{Reference Pantoja, Opiyo and Lewin30} Strengthening foundational interventions should precede or accompany efforts to address more complex challenges, and the environmental findings underscore the value of cross-sectoral collaboration to tackle multiple resistance drivers simultaneously.

Our study opens several avenues for future research. These include comparative analyses of perceived gaps against actual funding and policy attention, longitudinal tracking to determine whether priorities shift as context evolve, and intervention research testing whether addressing perceived gaps improves AMR outcomes.