Objective:

1. Understanding of AM global resistance problem

2. National strategy to combat the emergence and
spread AM resistance
- Prevent selection : Wisely use of AM
- Prevent transmission : General precaution
standard
3. The importance of Antimicrobial Stewardship
Program (ASP)
The problem of AM/AB resistance
 AM/AB resistance: global thread & challenge
- S. penumonia
- Ps. aeruginosa
- MRSA, VRE, MDR Gram-negative bacilli
- Acinetobacter banmannii
Yeoh, SF. ACCP, Singapore 2010.

 Widespread use of AM/AB: correlated with

increased incidence of bacterial resistance
Follath et al. Eur J Clin Microbiol, 1987.

 Appropriate changes in AB use can lead to

recovery of susceptibility
Ballow et al. Microbiol Infect Dis, 1992.
Discovery of new classes of antibacterial drugs
(1930’s to 2000’s)
 Kecepatan
penemuan
antibiotik

Timbulnya
resistensi
kuman

- Post antibiotic era

- Kembali ke zaman
pra antibiotik
- Peningkatan kematian
karena penyakit infeksi
Bagan
Spekulatif
Waktu
4
 Kecepatan
GOAL PPRA
penemuan
antibiotik

Timbulnya
resistensi
kuman

prevalensi
AMR
Surveillance
• standar
• berkelanjutan
Bagan
Spekulatif
Waktu
5
Prevent AM/AB resistance in health care settings

Prevent Wisely use

selection of AM/AB

General
Prevent precaution
transmission standard

* WHO report in infectious disease. WHO/CDS/2000.2

* CDC campaign to prevent AM resistance in health care
settings.
http://www.cdc.gov/drugresistance/healthcare/
ha/12steps_HA.htm
 GLOBAL ACTION PLAN
1. Improving awareness & understanding of antimicrobial
resistance through effective communication, education & training
2. Strengthening the knowledge & evidence base through
surveillance & research
3. Reducing the incidence of infection through effective
sanitation, hygiene and infection prevention measures
4. Optimizing the use or antimicrobial medicines in human &
animal health
5. Developing the economic case for sustainable investment that
takes account of the needs of all countries & to increase
investment in new medicines, diagnostic tools, vaccines
& other interventions
6. Strengthening International collaboration multidisciplinary to
promoteresearch & implementation of antimicrobial
resistance containment
 NATIONAL ACTION PLAN ON TACKLING
OF ANTIMICROBIAL IN INDONESIA (2017-2022)
(draft in human health)

1. Improving awareness & understanding of

antimicrobial resistance through effective
communication, education & training
2. Strengthening the knowledge & evidence base
through surveillance & research
3. Reducing the incidence of infection through
effective sanitation, hygiene and infection
prevention measures
4. Optimizing the use or antimicrobial medicines
in human & animal health
5. Developing the economic case for sustainable
investment that takes account of the needs of all
countries & to increase investment in new
medicines, diagnostic tools, vaccines
& other interventions
 STRUKTUR ORGANISASI
DIREKTUR RS

Tim PPRA Pilar PPRA

Ketua 1. Klinisi/wakil SMF
Wakil Ketua 2. Keperawatan
Sekretaris 3. Instalasi farmasi
Anggota 4. Lab. Mikrobiologi klinik
5. Komite PPI
SMF/Bagian 6. KFT
 TUGAS TIM PPRA
 Membantu pimpinan dalam:
- Menerapkan kebijakan-kebijakan tentang pengendalian
resistensi antimikroba (integrasi dengan 6 Pilar )
- Menetapkan kebijakan pengendalian penggunaan antibiotik
- Menetapkan program pengendalian resistensi antimikroba (PPRA)
- Memonitor dan mengevaluasi PPRA
- Menyelenggarakan forum diskusi/kajian pengelolaan penderita
penyakit infeksi
- Menyebarluaskan dan meningkatkan pemahaman dan
kesadaran tentang prinsip-prinsip pengendalian resistensi
antimikroba yang terkait dengan penggunaan antibiotik
secara bijak.
- Mengembangkan penelitian yang terkait dengan PPRA

Ref. PPRA RSCM: SK Dirut RSCM no. 7139/TU.K/34/VII/2009

 Komite Farmasi dan Terapi

 Pengendalian pedoman
penggunaan antibiotik
 Kebijakan penggunaan antibiotik
(antibiotic policy)
 Pembuatan & revisi pedoman
penggunaan antibiotik (antibiotic
guideline)
 Surveillance penggunaan
antibiotik Drug Use Study

Ref. Kuntaman & Paraton H. Workshop Pengampu PPRA, Denpasar 2011

 Komite PPI

 Pengendalian penyebaran mikroba

resisten
 Standar Precaution (kewaspadan standar)
 Isolasi penderita
 Penanganan unit kerja sumber mikroba
resisten (source control)
 Surveillance mikroba resisten
 Menyusun pedoman-pedoman terkait

Ref. Kuntaman & Paraton H. Workshop Pengampu PPRA, Denpasar 2011

 Pelayanan Mikrobiologi Klinik

 Laboratorium Mikrobiologi
 Identifikasi dan uji sensitivitas
 Hasil pemeriksaan mikrobiologi

 Konsultasi / Visitasi / Patient care

 Bersama klinisi ikut terlibat merawat
pasien infeksi.
 Turn Around Time report

 Informasi Pola kuman

 Pengelolaan data mikroba
 menerbitkan informasi peta medan
secara berkala
Ref. Kuntaman & Paraton H. Workshop Pengampu PPRA, Denpasar 2011
 Pelayanan Farmasi Klinik
 Pengelolaan dan Penggunaan antibiotik
 Menjamin ketersediaan dan mutu
antibiotik

 Konsultasi / Visitasi / Patient care

 Bersama Tim terlibat merawat pasien
infeksi ward pharmacist
 Mengkaji peresepan antibiotik
 Mengendalikan pemberian antibiotik
 Memonitor penggunaan antibiotik

 Informasi/konseling obat antibiotik

Ref. Kuntaman & Paraton H. Workshop Pengampu PPRA, Denpasar 2011
 The Concept of
INFECTIOUS DISEASE INTEGRATED SERVICE TEAM

KLINISI PERAWAT/BIDAN

SKFT
DALIN

FARMASI MIKROBIOLOGI
Klinik Klinik

Ref. Kuntaman & Paraton H. Workshop Pengampu PPRA, Denpasar 2011

Hospital Guidelines Antibiotic Use

1. Wisely use of AB
2. Surgical & non surgical prophylactic AB
3. Empirical treatment of AB
4. Definitive treatment of AB
5. Combination therapy
6. Antibiotic categories
7. Pharmaceutical aspect
8. Monitoring of effectivenes of AB

Ref. PPRA-RSCM, 2009

Empiric vs definitive AB therapy

- Initial empiric therapy

- guided by clinical presentation
- the most likely organism

- Definitive Therapy :
- use the narrow spectrum AB
Selecting and initiating an AB regimen

 Accurate diagnosis
- defining the host : immunocompr,
diabetes, age
- the site of infection
- clinical presentation  the most likely
microbiological etiology
- diagnostic specimen
- microbiological diagnosis
- detailed exposure history
- non infections condition for DD/

Leekha S, Terrel CL, Edson RS

Mayo Clin Proc 2011;86:156-157
Varley A J et al. Brit J Dnesth 2009;9:184-188
 Prudent use of AB
- Adequate data for diagnosis of infection(s)
- Right indication: treat infection not colonization
- AB selection: . efficacy
. safety
. suitability
. cost
- Right . dose
. interval
. route of administration
. duration
. Time of initiation
- Anaphylactic reaction?
- Patient education
Ref. - Gyssens 2005
- de Vries et al. Guide to good prescribing. WHO 1994
Fundamentals of Empiric Therapy
- Epidemiologic data/local data of AB profile &
sensitivity

- Clinical condition:
Serious inf. : - broad spectrum AB
- timeliness
- appropriateness
- duration of therapy
Mild inf. : Oral/parenteral

Ref. - Lawrence KL et al. Am J Respir-Crit Care Med. 2009;179:434-8.

- Peterson LR. CRIDTRHOPHID-ARCP. Faculty of Medicine Univ. of Indon.
March 10, 2012
FACTORS IN ANTIBIOTIC SELECTION

A. Spectrum: - the basic for empiric therapy

- concentration-dependent kinetics
- time-dependent kinetics

B. Tissue penetration: - lipid solubility

- molecular size and tissue
- adequacy of blood supply
- presence of inflammation

C. Antibiotic resistance: - natural/intrinsic or

acquired
- relative or absolute

D. Safety profile: avoid AB with serious/frequent

side effect

E. Cost
Ref. Cunka BA. Antibiotic essential, 2012
 Initial Appropriate Therapy
 Empiric broad-spectrum therapy initiated at the first
suspicion of serious infection (HAP, VAP, Sepsis)

 Selection of antibiotic to ensure adequate coverage of

all likely pathogens

 Factors to consider when defining appropriate therapy:

- microbiologic data
- monotherapy vs combination therapy
- dose and dosing frequency
- penetration
- timing
- toxicity
- risk of influencing resistance
- prior antibiotic use
Kollef MH, et al. Chest 1999;115:462-474
Kollef MH. Clin infect dis 2000;31(suppl 4):S131-S138.
 Merupakan pengelompokan
Access, antimikroba yang digunakan
Watch, saat ini guna untuk
and mengendalikan penggunaan
antimikroba berdasarkan
Reserve kewenangan yang ditetapkan
(AWaRe) oleh pimpinan rumah sakit.

Ref. Panduan Penatagunaan Antimikroba di Rumah Sakit. Kemenkes RI, 2020

Alur AWaRe

Ref. Panduan Penatagunaan Antimikroba di Rumah Sakit. Kemenkes RI, 2020

 Daftar Antimikroba Kelompok Access
 Amoksisilin  Oksitetrasiklin injeksi
Keterangan:
*: khusus untuk  Amoksisilin-asam  Pirimetamin
klavulanat
profilaksis bedah  Prokain penisilin
 Ampisilin
 Sefadroksil
 Ampisilin-sulbaktam
 Sefaleksin
 Benzatin benzil penisilin
 Doksisiklin
 Sefazolin *

 Eritromisin  Siprofloksasin (oral)

 Fenoksimetilpenisilin  Spiramisin
 Gentamisin  Streptomisin
 Kanamisin  Sulfadiazin
 Klindamisin (oral)  Tetrasiklin
 Kloksasilin  Tiamfenikol
 Kloramfenikol  Ko-trimoksazol oral
 Metronidazol
Ref. Panduan Penatagunaan Antimikroba di Rumah Sakit. Kemenkes RI, 2020
Daftar Antimikroba Kelompok Watch
 Amikasin  Sefiksim
 Azitromisin  Sefoperazon-sulbaktam
 Fosfomisin  Sefotaksim
 Klaritromisin  Sefpodoksim proksetil
 Levofloksasin  Seftazidim
 Moksifloksasin  Seftiakson
 Netilmisin  Sefuroksim
 Ofloksasin  Siprofloksasin injeksi

Ref. Panduan Penatagunaan Antimikroba di Rumah Sakit. Kemenkes RI, 2020

 Daftar Antimikroba Kelompok Reserve
 Aztreonam  Sefpirom
Keterangan:  Daptomisin **  Seftarolin
**: disediakan
melalui special
 Golongan  Teikoplanin
access scheme karbapenem  Tigesiklin
(SAS)
 Kotrimoksazol  Vankomisin
injeksi **
 Nitrofurantoin
 Linezolid **
 Piperasilin-
tazobaktam
 Polimiksin B **
 Polimiksin E **
 Sefepim
Ref. Panduan Penatagunaan Antimikroba di Rumah Sakit. Kemenkes RI, 2020
 DOSING STRATEGIES IN
HEPATIC/RENAL INSUFFICIENCY

Hepatic insufficiency
- problematic: no hepatic counterpart to the serum
creatinine to assesl iver function
- Severe liver disease:
1. decrease dose of hepatically
2. limited AB by 50%
3. use AB eliminated by renal route

Renal insufficiency
- Cr. clearance 40-60 ml/min: decreased dose of
renally eliminated AB by 50% with normal usual
dosing interval
- Cr. clearance 10-40 ml/min: 50% normal dose with
double dosing interval
- Use AB eliminated by hepatic route in usual dose

Ref. Cunka BA. Antibiotic essential, 2012

 Three principles for
Succesful AB prophylaxis
1. Patient should be at high risk
of infection
Antibiotic
Prophylaxis 2. The likely infecting organism
and their susceptibility
should be known

3. AB prop. only be
administered at time of risk

Varley AJ, Sule J, Absalom A.R.

Brit J. Anesth 2009;9:184-188
Factors for use of AB proph:

High risk groups :

 very young or very old age
 poor nutrition
 obesity
 diabetes
 smoking/history of smoking
 existing infection
 recent surgery
 extended hospital stay before the procedure
 certain congenital heart condition
Singh R, Singla P, Chandhany U Antibiotic Prophilaxis:
https://www.healthline.com/health/prophylactic-antibiotic-premedication.
 Recommended for various
surgical procedure to prevent SSI
 Should be :
- bactericidal
- non toxic
Antimicrobial - inexpensive
prophylaxis - active against the typical phatogen that
can cause SSI
 Administered IV : 30-60 min. before surgical
incision.
 Short duration  decreased toxicity

Enzler MJ, Berbari E, Osmon DR Mayo Clin Proc. 2011;86:686-701

  1. clean wounds : SSI rate :<2 %
- no inflammation
- elective, not emergency
Wounds - primarily closed
classification - Proph AB is not recommended
and risk of exept: clean surgery involving
enquiring the placement of a prothesis or
SSI
implant

Singh R, Singla P, Chandhary u.

International J Pharma Reasearch and Health Siciences 2014;22:203-2014
2. Clean contaminated wounds : SSI
rate :3-11%
- operation procedure enters into a
colonized viscus/cavity
- minimal spillage
- Prophylaxis AB is recommended
3. Contaminated wounds : SSI > 10 %
- major breaks in sterile technique
- gross spillage from GI tract
- the presence of infected bile/urine
- prophylaxis converted to treatment
regimen

4. Dirty wounds : SSI rate > 20 %

- active infection +
- Empirical AB treatment is
recommended

Singh R, Singla P, Chandhary u.

International J Pharma Reasearch and Health Siciences 2014;22:203-2014
  Aimed ; to reduce the incedence of SSI
Duration of  Tendency toward the use of shorter
course
Prophylactic
- In most surgery:single pre operative
AB - Caradiac surgery : - controversial area
- 48 hrs ?
- 56 hrs  32 hrs: NS
- Tunneled HD cath insertion : not
recommended
- Extruded TDC insertion: Single pre op
- PD cath replacement : Single pre op

1. Kappeller R, at al J. Antimicrobial chemotherapy 2012;67:521-522

2. Hamonda K, at al J. Cardiothorasic surg. 2015:10:25
3. Salman L, Asif H : Semin Dial. 209;22:297-299
  Renal transplantation : - single
preop.
 Vascular intervention :
- routine no AB
Duration of - special consideration single
prophylactic
AB (contd.) preop.
Non vascular Fluoroscopy:single
preop.
1. Orlando G et al Transplan Proc. 2010;42:1118-1119
2. Venkatesan AM et al J. Vasc Interv Radiol 2010;21:1611-1630
ASP Core Elements
 Leadership commitment
 Accountability: physician
 Drug expertise: single pharmacist
 Action: implementing recommended action
(ex. Systemic evaluation of on-going treatment)
 Tracking: monitoring AB prescribing
 Reporting: regular: AB use, AB resistant
 Education: resistance, good prescribing

Ref. Central for Disease Control and Prevention, CDC 24/7

www.cac.gov.getsneart/healthcare/implementation/core-element/html
7 Nov 2014
 ASP STRATEGIC PLANNING
A. Main strategies
STRATEGY METHOD PIC ADVANTAGE(S)
Prospective 1. Qualitative + 1. Med. doctors 1. Improving quality
auditing quantitative (specialist in 2. Reduce cost
auditing inf.)
2. AM resistancy 2. Clin. Pharm
monitoring 3. Clin. Microb.

Formulary - AM/AB monitoring - Doctors in Direct control of

restriction card charge AM/AB usage
On AM/AB - Licensed prescribers - Supervisors  Reduce misuse
use - AM/AB
committee
- Clin. Pharm.

Ref. - Pedoman umum penggunaan AB. Kemenkes RI, 2011

- Mc Dongall C, Polk RE. Clin Microb Rev. 2005;18:636-56
 Evaluation category of
Antibiotics Usage by Gyssens
0. Correct timing
I. Correct usage
II. Incorrect due to:
a) Incorrect dose b) Incorrect interval c) Incorrect route
III. Incorrect due to:
a) duration too long b) duration too short
IV. Incorrect due to: Alternative drug that is
a) more effective b) less toxic c) cheaper d) more specific
V No Indication
VI Medical record is insufficient to be evaluated
 SUMMARY

 AM/AB resistance: major problem across the

world
 Widespread use of AM/AB  increased incidence
of AM resistance
 Appropriate changes in AM/AB use can lead
to recovery of susceptibility
 Two strategies to prevent AM/AB resistance
- prevent selection: wisely use of AB
- prevent transmission: general precaution
standard
ARCP: Coordinating with 6 pillars
. Drug & therapeutic committee
. Clin. Pharm. Team
. Clin. Microbiology team
. Inf. Control committee
. Clinician
. Nursing staff

Integated service team  to control AB usage

. Hospital guidelines AB use

. Standard operating procedure
. Antibiotic stewardship program
 preventing antimicrobial resistance