NRL for Control and Monitoring of Antimicrobial Resistance

National Reference Laboratory “Control and Monitoring of Antimicrobial Resistance” is ISO 17025 certified and is also certified for its regular participation in the - Germany.

1. National Reference Laboratory “Control and Monitoring of Antimicrobial Resistance” is the national reference laboratory responsible for the detection and investigation of antibiotic resistance. NRL “CMAR” studies and investigates all aspects of antibiotic resistance, in particular confirmation, interpretation and also molecular investigation of new or unusual resistance traits.

The laboratory collects and tests referred isolates, principally those considered to have unusual resistance. NRL “CMAR” performs Disk Diffusion Method for Antimicrobial susceptibility testing and if necessary also Minimum inhibitory concentrations (MICs) of relevant antibiotics are determined. NRL “CMAR” advises on which agents may be appropriate for therapy and on any public health risk.

2. External Quality Assessment Scheme
National Reference Laboratory “Control and Monitoring of Antimicrobial Resistance”, together with the Bulgarian Association of Microbiologists (BAM), conducts the External Quality Assessment Scheme for microbiology laboratories in Bulgaria.

3. NRL “CMAR” also administrates Bulgarian Surveillance Tracking of Antimicrobial Resistance (BulSTAR).
The Department of Microbiology in NCIPD, in coordination and cooperation with the Bulgarian Association of Microbiologists (BAM) collects and analyzes annual routine susceptibility test data reports from almost all state microbiology laboratories of the public health facilities, and a significant number of private microbiology laboratories throughout the country.

The reports include all clinically significant microorganisms, isolated in the collaborating centers, and their sensitivity to more than 50 antimicrobial agents, tested routinely in the participating laboratories using a nationally adopted standardized method and an element of a rule-based result checking, applied before the data have been accepted and proceeded for analysis.

Currently BulSTAR is a national network of 166 microbiology laboratories – 13 public laboratories, 82 hospital ones, and 71 private laboratories, covering practically in 2013 the whole population in all the regions and counties of Bulgaria. A small working group in NRL “CMAR” organizes and conducts the surveillance process.

Each year “CMAR” laboratory summarizes the results in annual reports, the latter being sent back to the collaborating centers and made available to the public on the Internet site of Bulgarian Association of Micrbiologists (BAM).

4. Educational courses
NRL “CMAR” conducts a specialized educational course for graduated medical doctors, biologists and laboratory technicians on the issues of mechanisms and surveillance of antimicrobial resistance.

5. Specialized studies
NRL “CMAR” also undertakes commissioned studies to evaluate the in-vitro activity of novel antibacterial agents against tailored panels of bacteria, consisting of characterised strains with defined resistance mechanisms, and recent multi-resistant clinical isolates. As an ISO 17025 certified laboratory NRL “CMAR” participates and offers collaboration upon national and international projects and programs in the field of medical microbiology, surveillance of antimicrobial resistance and antibiotic consumption.

6. Microbiological testing with determination of antimicrobial susceptibility (antibiogram)
NRL “CMAR” has proven authority in Bulgaria and worldwide. We offer the possibility for microbiological testing with determination of antimicrobial susceptibility (antibiogram) of the most important human pathogens. The laboratory is equipped with the latest appliances and apparatuses for modern diagnostics and antimicrobial susceptibility testing, including rapid-diagnostic equipment: VITEK “bioMerieux”, Micronaut “Merlin” etc. Among the diagnosed materials and samples are: uroculture (urine samples), vaginal and cervical swabs, prostate secretes, urethral swabs, throat, nasal, eye and ear secretes, sputum, wound secretes, etc.

Sector "Nosocomial infections"

• Participates in the process of development and implementation of the Medical standard for prevention and control of nosocomial infections.
• Develops, proposes for approval by the Minister of Health and participates in the implementation of the National Programme for Prevention and Control of nosocomial infections and the spread of antimicrobial resistance / AMR /.
• Participates in the annual evaluation of data from the national epidemiological surveillance of nosocomial infections and in representing Bulgaria to the European Surveillance Network of nosocomial infections.
• Counsels and assists the orderly conduct of studies on nosocomial infections at national and regional level and in individual hospitals.
• Participates in the coordination of the microbiological confirmation by reference methods of nosocomial agents with growing epidemic relevance and involved in outbreaks. Molecular genetic methods are developed and implemented to identify and characterize mechanisms of resistance to antimicrobials (ESBL, carbapenemases, etc.).
• Contemporary diagnostic genetic tests for identification of Clostridium difficile and toxin determination are performed in NRL-CMAR directly in clinical material (stool sample) of outpatient and hospitalized patients. Various of PCRs, running in real time (real time PCR) with high sensitivity and specificity are applied.
• C. difficile is isolated and confirmed by phenotypic and genetic methods. The cultured strains with high epidemic potential can be characterized by adopted standard European molecular methods (PCR-ribotyping and Multilocus variable number tandem reapeat analysis, MLVA7) for investigation of genetic relatedness and hospital outbreaks.
• Develops standard protocols for epidemiological typing of indicator bacterial species by molecular genetic methods: ESBL-producing members of the family Enterobacteriaceae, multi-resistant Pseudomonas aeruginosa and Acinetobacter baumannii, carbapenem-resistant Enterobacteriaceae and others.
• Proposes and assists in various training programs on antibiotic resistance and the control of nosocomial infections together with medical and non-medical universities.
• Participates in conducting of various training courses as well as postgraduate programs for medical doctors, biologists, health care professionals and other personnel working in hospital settings.