1. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 CAESAR Central Asian and Eastern European Surveillance on Antimicrobial Resistance Dr Nienke van de Sande Technical officer AMR On behalf of the AMR programme WHO Regional Office for Europe

2. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 European Strategic action plan on antibiotic resistance 1.Strengthen intersectoral coordination 2.Strengthen surveillance of antibiotic resistance 3.Promote rational use and strengthen surveillance of antibiotic consumption 4.Strengthen infection prevention and control and surveillance in health care settings 5.Prevent emerging resistance in veterinary and food sectors 6.Promote innovation and research on new drugs 7.Improve awareness, patient safety, and partnership

3. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 CAESAR Central Asian and Eastern European Surveillance on Antimicrobial Resistance Network of national surveillance systems for antibiotic resistance in all countries of the WHO European Region that are not part of EARS-Net (European Antimicrobial Reistance Surveillance Network) run by ECDC (European Centre for Disease Prevention and Control). Provide comparable and validated data on the prevalence and trends of antimicrobial resistance in a core group of invasive bacteria. CAESAR methodology is fully compatible with EARS-Net

4. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 EARS-Net European Antimicrobial Resistance Surveillance Network at ECDC Methodology  Blood and CSF isolates  Sensitive (S), Intermediate (I), Resistant (R) interpretation  MIC, Zone diameter, Etest results  Basic patient characteristics (Age, Gender, ICU) Pathogens under surveillance  S. aureus (MRSA)  S. pneumoniae (Pen R)  E. coli (ESBL, Carbapenemases)  K. pneumoniae (ESBL, Carbapenemases)  E. faecium and E. faecalis (VRE)  P. aeruginosa (MDR)  Acinetobacter spp. (MDR) Percentage isolates per bacteria, 2013 Data from EARS-Net, ECDC

5. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Example of EARS-Net data. K. pneumoniae: percentage of invasive isolates resistant to carbapenems, 2005, 2010 and 2013. EARS-net data from ECDC 2005 2010 Colistin resistance 8.8% 2013 Arrows indicate significant decreasing and increasing national trends for 2010-2013

6. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 CAESAR & EARS-Net structure Laboratories National level International level Data collection and Laboratory procedures standardized: -CAESAR manual/EARS-Net reporting protocol -Standard Operating Procedures -EUCAST or CLSI guideline -Quality assurance (national and international) -Reference laboratory/National coordination center

7. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 CAESAR & EARS-Net structure Laboratories National level International level Feedback to National level and Laboratories: -Summary of AMR data -Data quality and Confirmation of results -Unusual resistance phenotypes CAESAR/EARS-Net EQA: -6 strains send to laboratories by UK-NEQAS (PHE) -Laboratories receive Individual feedback reports

8. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 CAESAR & EARS-Net Only blood isolates and CSF are collected Countries are encouraged to expand national AMR surveillance according to local needs and capacity Tip of the iceberg, but a good start!

9. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Country situation analysis –Visit key Ministries, institutions, agencies, laboratories –Mission report with observations and recommendations Goal –Appointment of National AMR Focal Point (ToR) –Installation of Intersectoral Coordination Mechanism (ToR) –Development of national AMR action plan (Country examples) –Define needed steps to start participating in CAESAR Follow-up activities: Consultancy, Twinning, Stakeholder meetings, …

10. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 National and Multi-country workshops Main topics national workshops: -EUCAST guidelines, principles of antmicrobial susceptibility testing and interpretations -Quality control and the Role of a National AMR reference center -CAESAR methodology, national AMR surveillance, epidemiology, WHONET

11. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 CAESAR - Expanding AMR surveillance throughout Europe Countries submitting data to CAESAR Countries visited for CAESAR participation Countries to be visited for CAESAR participation Countries participating in EARS-Net 13 countries participated in the CAESAR-EQA in 2014

12. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Main CAESAR challenges Laboratory capacity: appropriate species ID, standardized AST, harmonization of breakpoints, EQA Education of laboratory personnel Implementation of updated guidelines and SOP in laboratory practice Improve sampling habits and utilisation of medical microbiologic diagnostics Improve laboratory information management Health System Strengthening / Quality Control / Sustainability

13. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Upcoming CAESAR activities National AMR workshops and Country situation analysis First CAESAR Annual Report 2014 Feedback CAESAR EQA 2014 & prepare EQA 2015 Pilot Proof-of-principle study to Improve sampling habits and utilisation of medical microbiologic diagnostics in Tbilisi, Georgia Multi-country workshop with focus on the role of an AMR reference centre, February 2015, Copenhagen, Denmark CAESAR Network meeting at ECCMID, 25-28 April 2015, Copenhagen, Denmark

14. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Partnership

15. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 CAESAR project group CAESAR Project Group ESCMID - Assoc. Prof Christian Giske, Dr. Robert Skov RIVM – Dr. Tjalling Leenstra, Jos Monen WHO Europe – Dr. Danilo Lo Fo Wong, Dr. Saskia Nahrgang, Dr. Nienke van de Sande Pool of experts Dr Bela Kosciz (Hungary), Roman Kozlov (Russia), Prof Arjana Tamic (Croatia), Dr Iva Butic (Croatia), Dr Oskar Ekelund (Sweden), Ass. Prof. Onur Karatuna (Turkey), Katja Seme (Slovenia), Prof Waleria Hryniewicz (Poland), Prof Jan Prins (The Netherlands), Prof Murat Akova (Turkey), Dr Nandine Shetty (United Kingdom), Marieke van der Lubben (The Netherlands), Rob Riesmeijer (The Netherlands), Dr Peet Tul (Sweden), Dr Osman Cirit (Turkey), …

16. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Acknowledgments WHO Europe Division of Communicable Disease, Health Security & Environment –Guenael Rodier –Cristiana Salvi AMR Coordination –Danilo Lo Fo Wong –Nienke van de Sande-Bruinsma –Saskia Nahrgang Food Safety –Hilde Kruse Alert and Response Operations –Ana Paula Coutinho –Jukka Pukkila Health Technologies and Pharmaceuticals –Hanne Bak Pedersen –Nina Sautenkova –Ganna Bolokhovets Health Systems and Public Health –Hans Kluge Influenza & other Respiratory Pathogens –Caroline Brown Vaccine Preventable Diseases & Immunization –Robb Butler WHO Country offices

17. Strengthening the fight against antimicrobial resistance in Bosnia and Herzegovina: current situation and future challenges, 29 October 2013 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 Surveillance of Antimicrobial Resistance for Local and Global Action Stockholm, Sweden December 2-3, 2014 CAESAR/AMR focal points Non-EU member states: Dr Lindita Molla (Albania) Dr Kristina Gyurjyan (Armenia), Dr Nazifa Mursalova (Azerbaijan), Prof Leonid Titov (Belarus), Prof Mirsada Hukic, Dr Amela dedeic-Ljubovic & Dr Pava Dimitrijevic (Bosnia Herzegovina), Prof Paata Imnadze (Georgia), (Israel), Dr Lul Raka (Kosovo*), Dr Baktygul Ismailova & Dr Baktygul Kambaralieva (Kyrgyzstan), Dr Golubinka Bosevska (FYR Macedonia), Dr Radu Cojocaru (Moldova), Prof Gordana Mijovic (Montenegro), Prof Roman Kozlov (Russia), Prof Zora Jelesic (Serbia), Dr Andreas Kronenberg (Switzerland), Dr Azamjon Safolovich Mirzoev (Tajikistan), Dr Husniye Simsek (Turkey), Dr Gurbangul Ovliyakulova (Turkmenistan), Dr Aidyn Salmanov (Ukraine), Dr Gulnora Abdukhalilova (Uzbekistan) *in accordance with the United Nations Security Council Resolution 1244 (1999)