Antimicrobial Stewardship

Program in Hosptial

Muchlis Achsan Udji Sofro

Divisi Tropik Infeksi
Departemen Ilmu Penyakit dalam FK UNDIP
RSUP Dr Kariadi Semarang
AAW 2019

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 DR Dr Muchlis Achsan Udji Sofro, SpPD-KPTI

• Pemalang, 19 Maret 1963

• Pembina Utama : IV-E
• Isteri: DR Dr Retnaningsih SpS-K, KIC. Anak: Annisa Laras SPsi
• Amanah:
• Ketua KSM Penyakit Dalam RSUP Dr Kariadi
• Kepala Divisi Tropik Infeksi, Bagian Ilmu Penyakit Dalam FK UNDIP
• Ketua Tim HIV RSUP Dr Kariadi
• Anggota Komite Pengendalian Resistensi Antimikroba (KPRA) Kemenkes RI
• Anggota Panel Ahli HIV Kementrian Kesehatan RI

• HP: 08122916803 email: muchlis.aus@gmail.com

muchlis aus AAW 2019 2

Introduction

• Managing serious infections is :

• a balance between providing timely and
• appropriate broad-spectrum empirical therapy for individual
patients

• Which has been consistently shown to:

• improve outcomes, and
• reducing unnecessary use of antimicrobial agents  Which may
contribute to the development of antimicrobial resistance.

3
 SURVEILLANCE: ANTIBIOTIC QUALITATIVE
6 TEACHING HOSPITALS - 2016
100
100
80 SURGICAL 80 MEDICAL
60 60
40 40
20 20
0 0
0 I II III A IV V VI 0 I II IIIA IV V VI
RS A RS B RS C RS D RS E RS F RS A RS B RS C RS D RS E RS F

AMR Surveillance -2016 Survai MRSA isolat klinik di 8 kota di

Prevalence of E coli & K. pneumoniae (ESBL+) Indonesia
65.22
70.00
60.00 51.56
100% 82% 78% 79%
50.00
36.07 35.71 33.90 32.47
40.00
80% 25.40 22.58
30.00

60% 53% 52% 55% 50% 56% 20.00

10.00
0.00 Kota
40%

Aceh

Bali
Medan

Solo
Pbaru

Malang

Surabaya

Semarang
19%
20%
0%
ACH MED JAK SEM SOL SUB MAL DPS SWA %MRSA
SUB

4
To control the spread of antimicrobial
resistance:
• hospitals commonly implement programs designed to
optimize antimicrobial use

• supported by infection-control measures

5
Institutional efforts to optimize
antimicrobial
• concentrate on patient outcomes
• multidisciplinary support  FORKIT (Forum Kasus Infeksi
Terpadu)
• use a combination of interventions:
• customized to the needs,
• resources, and
• information technology infrastructure of the health care
institution.

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Hospital-based antimicrobial management
programs:

also called “antimicrobial stewardship programs”

• are primarily based on education
• restricting the availability of selected antimicrobial
agents
• reviewing broad-spectrum empirical therapy
• streamlining or discontinuing therapy, as indicated
on:
• the basis of culture and susceptibility testing results
and
• clinical response.

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 Antimicrobial Program
CDC , 2018
• Implement infection prevention and control programs,
and antibiotic stewardship programs in healthcare
settings
• Establish or strengthen national tracking systems to
respond rapidly to outbreaks, identify emerging
pathogens, and track trends
• Enhance laboratory capacity to detect and report
resistance
• Develop and implement national action plans to
address the threat of antibiotic resistance

September 2018, the U.S. is launching the AMR Challenge at a United Nations General Assembly 8
The AMR Challenge
five commitment areas:
• tracking and data
• infection prevention and control
• antibiotic use
• sanitation and environment and vaccines,
• therapeutics and diagnostics.

CDC. Page last reviewed: September 19, 2018

9
ESBL PRODUCING
BACTERIA

PREVALENCE of ESBL in INDONESIA

70
surveill
60 60 ance
2016
50
presentage

45-82%
40 40 WHO/
35 PPRA
30 28 26- ESBL
RSD 56%
20 RSD S
10 S
9 AMR
0 IN
2000 2005 2010 2013 2016
11
hospitals to control the spread of antimicrobial
resistance. Infection-control measures

• isolating patient contacts

• the cohorting of patients
• performing environmental cultures and
• removing contaminated devices

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Education as a Means to Decrease
Antimicrobial Resistance
• to increase physicians’ understanding about the scope and
consequences of antimicrobial resistance
• appropriate use of antimicrobial agents
• is relatively inexpensive and easy to implement in hospitals.
• Therefore, many institutions supplement education with a formal
antimicrobial stewardship program.

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The influence of such programs is limited by

• lack of institutional support;

• only short-lived, if any, changes in prescribing
practices; and
• inadequately documented correlation between the
educational initiative and the decrease in antimicrobial
resistance ?

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Restriction of Antibiotic

• use of a very broad array of antimicrobial agents:

• third-generation cephalosporins
• Fluoroquinolones
• carbapenems or
• b-lactam/b-lacta- mase inhibitor combinations)
• for non-ICU patients

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PMK No.8
th 2015

Standard MMU.1.1:
The hospital develops and implements a program
for the prudent use of antibiotics based on the
principle of antibiotic stewardship (ASP).
 PENATAGUNAAN ANTIBIOTIK / PGA
Peningkatkan keselamatan pasien
• Melalui pengendalian
• Penggunaan antibiotik optimal Tepat Jenis, dosis,
route, interval dan durasi.
• Tepat indikasi
• Tepat prosedur

Ohl CA. Seminar Infect Control 2001;1:210-21. / Ohl CA, Luther VP. J. Hosp. Med. 2011;6:S4/ Dellit TH, et. al. Clin Infect Dis. 2007;44:159-177

Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, 2016. Implementing an antibiotic stewardship program: guidelines by the infectious diseases society of America and the society for
healthcare epidemiology of America. Clin Infect Dis.

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STRUKTUR PGA

DIREKTUR

KPRA
PPRA

PGA
 LANGKAH PGA
Pastikan PNPK; PPK; CP
1
Bentuk tim PGA.
2 sudah direvisi

4
3
SMF/KSM Kesehatan anak
5 • CAP – Children
• Neutropenia

Pelatihan dan pendidikan Pilot project intervensi

 Aktivitas PGA sehari hari
Dr. Djovi. SpPD
RS. Super husada

R / Meropenem
1 g no X
/ imm.

Ny. Rindu

Ms. Rindu. 46 Discussion:

yrs
BP110/70,
Tim Meronem 
Levofloxacin 750
TEMP: 38.5,
Leucosit: 14.000. PGA mg
X-Ray Thorax:
Pneumonia (+)
Diagnose: CAP
 PGA: Pembedahan  Prophylaxis
Dr. Djovi. SpB KL
RS. Super husada

R / ceftriaxone I g No Antibiotic
No. II
/ imm.

Tn. ABD

Ny. N. 40 yrs
Benjolan pada
leher; BP110/70, • Pasien pulang
TEMP: 36.5,T3/T4 • obat analgetik
DBN; Leucosit: • Antibiotik oral (-
7.000. )
Diagnose: Struma
 AWaRe in perspective:
options for
monitoring, guidelines and
policies
Regional Workshop to optimize AB use
13th February 2019

Nicola Magrini
Secretary,
WHO Expert Committee on the Selection and Use of Essential Medicines,
Essential Medicines Department, WHO

22
Gejala yang sering muncul/berat
dan perlu Antibiotik

AWARe, WHO, 2019

 PANDUAN
PENATAGUNAAN ANTIBIOTIK
DI RUMAH SAKIT

Edisi 2020

KEMENTERIAN
KESEHATAN

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Antibiotik kelompok Access :

• Tersedia di fasilitas pelayanan kesehatan sesuai dengan

ketentuan tingkat pelayanan kesehatan untuk pengobatan
infeksi bakteri.
• Diresepkan oleh dokter, dokter gigi, dokter spesialis, dan
direview oleh apoteker.
• Penggunaan sesuai dengan Panduan Praktik Klinik dan
Panduan Penggunaan Antibiotik yang berlaku.
Access

• Amoksisilin, Ampisilin • Metronidazol

• Amoksisilin-asam klavulanat • Nitrofurantoin
• Ampisilin-sulbaktam • Tetrasiklin, Netilmicin
• Benzatin benzilpenisilin • Prokain penisilin
• Doksisiklin • Sefadroksil
• Eritromisin • Sefaleksin
• Gentamisin • Sefazolin *
• Klindamisin (oral) • Siprofloksasin (oral)
• Kloksasilin • Tiamfenikol
• Kloramfenikol • Trimethoprim+sulfametoksazol
(kotrimoksazol oral)

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Antibiotik kelompok Watch :

• Tersedia di fasilitas pelayanan kesehatan sesuai ketentuan

tingkat pelayanan kesehatan untuk pengobatan infeksi
bakteri.
• Digunakan untuk indikasi khusus atau ketika antibiotik Watch
tidak efektif.
• Kelompok ini potensi resistensi lebih tinggi, diprioritaskan
target utama program pengawasan dan pemantauan.
Watch

• Diresepkan dokter spesialis, direview apoteker; disetujui

dokter konsultan infeksi.
• Apabila tidak tersedia dokter konsultan infeksi persetujuan  dokter
yang ditetapkan pimpinan rumah sakit.
• Penggunaan sesuai Panduan Praktik Klinik dan Panduan
Penggunaan Antibiotik yang berlaku
Whatch

• Amikasin • Sefoperazon- sulbaktam

• Azitromisin • Sefotaksim
• Fosfomisin (oral) • Seftazidim
• Klaritromisin • Seftriakson
• Levofloksasin • Siprofloksasin (inj)
• Moksifloksasin • Polimiksin E (oral)
• Sefiksim

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Antibiotik kelompok Reserve:

• Pilihan terakhir pada infeksi berat yang mengancam jiwa,

disebabkan MDRO.
• Dicadangkan mengatasi munculnya MDRO.
• Prioritas program pengendalian resistensi antimikroba
nasional dan internasional, dipantau dan dilaporkan
penggunaannya
• Diresepkan dokter spesialis  indikasi tertentu, direview
apoteker, disetujui oleh tim Antibiotic Stewardship
Programme (tim Penatagunaan antibiotik)  PPRA - RS.
Reserve

• Aztreonam • Piperasilin-tazobaktam
• Daptomisin** • Polimiksin B**
• Fosfomisin (inj) • Polimiksin E (inj)**
• Kotrimoxazol (inj) • Sefepim
• Linezolid • Seftarolin
• Meropenem • Teikoplanin
• Tigesiklin
• Vankomisin

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Persetujuan peresepan antibiotik

Pasien Perawat

ACCES Farmasist
PPDS
RESEP WATCH Supv.
DPJP
RESERVE Tim ASP
tidak sesuai

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 Revisi 2020

Revisi 2019
ARCP guideline in Hosp.
(PMK no.8/2015)

Standar Nasional
Akreditasi RS
Edisi 2017

ASP
JCI Accreditation
6th ed- 2017

Perkembangan PPRA di Indonesia

35
Standard MMU.1.1:
The hospital develops and
implements a program for
the prudent use of
antibiotics based on the
principle of antibiotic
stewardship.

36
JCI edisi 6 - 2017

37
38
39
40
PENDUKUNG ASP/PGA

• Implementation of Computerized
Decision Support System (CDSS)
• Mikrobiologi klinik
• Farmasi klinik
• Pengendalian dan Pencegahan
Iinfeksi
• Monitoring dan audit
• Guideline, regulasi lokal

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Point-of-care interventions are a valuable
component of antimicrobial stewardship

POINT-OF-CARE
• DIAGNOSIS YANG TEPAT
• review pilihan antibiotik
• pilihan antibiotik definitif
berdasarkan hasil kultur
• penetapan dosis yang sesuai
kebutuhan pasien
• de-eskalasi/eskalasi
• monitoring terapi
• automatic stop orders.
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Program Pengendalian AMR di Indonesia
Appropriateness
• Surveillans AMR Indonesia
Year 2013 Use of AB
• januari 2019  Inline dengan GLASS_WHO

40% • Pedoman antibiotic nasional sudah finalisasi

(26.7%-56.8%) • AWARE  masuk dalam Pedoman Nasional
AB dan FORNAS.
• Revisi Permenkes 8/2015 PPRA di RS 
PPRA di Faskes  tahap penyelesaian
• National Action Plan  finalisasi

Year 2017

60%
Prevalence of AMR
(50%-82%)

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• Terimakasih

44