Carbapenem-resistant Enterobacterales in Europe: strengthening AMR resilience through coordinated system-level action - lessons from Ukraine.

Carbapenem-resistant Enterobacterales (CRE) have emerged as one of the most serious antimicrobial resistance (AMR) threats in Europe. Rising incidence, substantial mortality, and marked heterogeneity across the EU/EEA pose a growing challenge. In Ukraine, an already substantial AMR burden and pre-existing limitations in diagnostic and infection prevention capacity, infectious diseases and antimicrobial stewardship (AMS) expertise, workforce resources, and access to effective antimicrobials have been further exacerbated by the war, including through damage to healthcare infrastructure and disruption of supply chains. These conditions facilitate the emergence and spread of CRE. As patient movement across Europe continues, CRE in Ukraine has become a shared European health security challenge. Although numerous national and international initiatives support AMR control in Ukraine, their impact is limited by fragmented implementation, insufficient coordination, and limited visibility across stakeholders. Drawing on hospital partnerships, multidisciplinary expert discussions, and emerging national coordination efforts in Ukraine, we argue that sustainable CRE control requires an integrated, system-level framework combining strengthened microbiological diagnostics and surveillance, infection prevention and control, infectious diseases and AMS expertise, and equitable access to effective antimicrobials. These components should be embedded within a coordinated national framework that aligns international support with national priorities. We describe the recently established, Ukrainian-led Public Health Center of the Ministry of Health of Ukraine (PHC) AMR Coordination Working Group as an emerging example, combining regular technical engagement, structured stakeholder collaboration, and plans to map international AMR-related activities in Ukraine. This approach may inform future European efforts to organise international AMR support in other high-burden and crisis-affected settings.