Aiming at concrete results: The first SEE Regional Workshop on Antimicrobial Resistance took place in Sofia, Bulgaria, 29-30 November 2013

The first SEE Regional Meeting took place in Sofia and was organized by the Bulgarian
Ministry of Health to address the issue of antibiotic resistance in its through the SEE Health Network  (SEEHN) designated  Regional Health Development Center (RHDC).
The RHDC is hosted by the National Centre of Infectious and Parasitic Diseases (NCIPD) which is under the Ministry of Health. It builds on the existing institutional, human and technical resources of the NCIPD in line with the Memorandum of Understanding on the future of the SEEHN and the plan for establishment and development of the RHDCs in the SEEHN member states.

The purpose of the event was to bring together all focal points on antibiotic resistance of the 10 SEEHN member-states and to convene a 1,5 days discussions on the most important issue of antibiotic resistance surveillance in the SEE region. The meeting was also attended by a representative of Turkey as an affiliated to the SEEHN for this special meeting. The National Centre of Infectious and Parasitic Diseases used to have a long standing collaboration with the Public Health Institute of Turkey and their participation was valuable and beneficial for the future partnerships of the RHDC.The meeting was also attended by the representatives of some of the regions in Bulgaria who participate in the national BULSTAR surveillance system of AMR.

During this first meeting, the participants (focal points on antibiotic resistance of the 9 SEEHN countries) together with the nationals from the regions had the opportunity to discuss different important issues and problems faced by the countries and related to future plan of work of the SEEHN RHDC on antibiotic resistance. The participants received a disc with all important official documents related to the establishment and functioning of the SEEHN: MoU, Decision on the establishment of RHDCs and Host Agreement.

A special Questionnaire - SELF-ASSESSMENT SURVEY ON ANTIMICROBIAL RESISTANCE was prepared by the SEE RHDC in advance and sent to all focal points. The questionnaire was based on the WHO EURO documents and builds upon the strategic objectives of the European Strategic Action Plan on Antimicrobial Resistance. The data received have been processed by the SEE RHDC, reported and discussed during the meeting. Some recommendations for further implementation of the objectives of the European Strategic Action Plan on Antimicrobial Resistance have been made.

The most significant 5 bacterial pathogens in hospitals in the region are:  Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus, Acinetobacter baumannii, Escherichia coli, Enterococcus faecium; and in ambulatory care are: Escherichia coli, Staphylococcus aureus , Streptococcus pneumonia, Klebsiella pneumoniae, Enterococcus faecium.

 

The main causes of drug resistance were determined as overuse of antibiotics, use of drugs without reasonable indications, inadequate infection control and stewardship of antibiotic use in health care settings, insufficient practical education on antibiotic use during undergraduate education, uncontrollable use of antibiotics in animal sector, imperfect laboratory diagnosis, lack of adequate therapeutic guides, lack of awareness of the general population, inappropriate  dose and duration of treatment and the absence of systematic monitoring of drug use in the medical, veterinary and food industries.

 

All countries have national focal point for antimicrobial resistance. Only three of them (Croatia, Macedonia and Montenegro) have functional national coordinating committee on antimicrobials/AMR. All countries have reference laboratories. BiH Federation/BIH and the Republic of Moldova are in process of establishment. There are reports for MRSA, carbapenemases, PNSSP, VRE, but not for ESBL in 3 countries (Croatia, Republic of Moldova and the Republic of Serbia).  All countries use for detection of AMR phenotype methods, determination of MIC and genetic methods.

Most countries celebrate the European Antibiotic Awareness Day. They have different activities. In all countries doctors, hospital health care workers, community health care workers have some education on AMR, as part of their general education, but there isn’t enough specific educational programs in this field.

The experience of Bulgaria:

 

The Antibiotic Resistance Surveillance System in Bulgaria BULSTAR which started in 1997 was discussed on a large scale, with emphasis on the standardization of laboratory methods through internal and external quality assessment system, monitored materials from in-patient and out-patient health establishments, most frequently isolated microorganisms in different materials, etc.

The resistance to 30 antibiotics is reported annually on central level to the central reference laboratory of the National Center on Infectious and Parasitic Diseases. The system covers the whole territory of the country comprising of 166 microbiological labs. Out of 38 505 hospital beds the system covers 22 812 hospital beds. 70 private labs are also participating in the system, responsible for out-patient health establishments. The data received are supportive for developing therapeutic guidelines and hospital policies for coping with antibiotic resistance. The pharmaceutical companies in Bulgaria also use these data.

Although the antibiotic consumption in Bulgaria for 2008-2010 is 24,6-22,5 DDDs per 1000 population per day, the antibiotic resistance is increasing. The main reason for this is the overuse and misuse of cephalosporin’s followed by penicillin’s alone and in combination with inhibitors. Resistance to Gram-negative bacteria such as Escherichia coli and Klebsiella pneumonia is rapidly increasing in Bulgaria too. During the last five years the production of ESBLs has doubled in hospital settings. Resistance to methicillin by Staphylococcus aureus (MRSA) in total is 10% while the invasive resistance is much higher. The issue of reduction in the prevalence of antibiotic resistance by addressing the use, overuse and misuse of antibiotics in all sectors such as: health care, veterinary and agricultural settings, etc. is also a priority for Bulgaria. Preliminary discussions on inter-sectorial level have been carried out but the results are not promising.

The presentations given by the Focal Points of Bosnia and Herzegovina,  Croatia, Israel, Montenegro, republic of Macedonia, Republic of Moldova and the Republic of Serbia on the current situation of AMR delineated some interesting and debatable issues characteristic for all countries: policy development, updating of legislation, networking, establishment of inter-sectorial coordination mechanism at ministerial level, improvement of communication between sectors, rational use of antibiotics, standardization of methods, internal and external quality assessment systems, data management, training of professionals and capacity building in management, lack or insufficient guidelines in some countries, surveillance system in one country (Montenegro) not in place, growing awareness to nosocomial infections, high expenses of some tests and related financial pressure posed on microbiologists from hospital directors, streamlining of expenses, overuse of broad specter antibiotics related to some extend to their lower price compared to narrow specter antibiotics (first and second generation cephalosporin’s), involvement of private sector on larger scale, targeting general public on permanent basis, constant awareness campaigns for different target groups,

The representative of Turkey also gave a short presentation. Turkey started their surveillance system of antibiotic resistance three years ago. They have approximately the same problems as the SEEHN member-states. They are eager to share their data during the next meeting of the Network.

During the meeting the following topics associated with antibiotic resistance surveillance system, introduced by the Bulgarian professionals of the RHDC, were discussed by participants:

·         Communicable disease surveillance system  in Bulgaria
·         Epidemiology and antifungal susceptibility of clinically significant fungi
·         Advances in molecular surveillance of healthcarе associated infections in Bulgaria
·        Phenotypic methods for routine detection of antibiotic resistance mechanisms in Gram negative bacteria: the experience of a cancer hospital in Bulgaria
·        Antimicrobial susceptibility of human extra-intestinal non-typhoid Salmonella isolates in Bulgaria, 2005-2012
·         Current and emerging mechanisms of antimicrobial resistance in Bulgaria
·         TB Surveilance in Bulgaria
·         Characterization of methicillin-resistant Staphylococcus aureus isolated in Bulgaria
·         The relationship between antibiotic consumption and antimicrobial drug resistance - general concepts
·         COMBACTE network and research opportunities on the Balkans

Information on the specialty of microbiology in the SEEHN countries has been exchanged.

In some countries like Israel the specialization differs for doctors and biologists which is the American model. In Europe it is different. The specialty of clinical immunology was also raised and information exchanged.

 

The participants of the meeting reached a common opinion that the establishment of an inter-sectorial coordinating mechanism for antibiotic resistance surveillance at ministerial level is essential.

The possibilities for collaboration and future work have been discussed at the end of the meeting, namely:

1. Approaching TAIEX on behalf of Macedonia or eventually another SEEHN country for organizing the next meeting of the Focal Points of RHDC based on the Draft Decision on the collaboration between SEEHN and EC/TAIEX in 2014 approved during the 32^nd Plenary Meeting of the SEE Health Network in Podgorica, Montenegro, November 2013.
2. Mutual work of all member-states for preparation of educational programs for medical doctors, hospital health care workers, and community health care workers.