Peran Apoteker - MDR

Peran Farmasis dalam Menghadapi
Penyebaran Resistensi Antimikroba dan

Obat Berganda
L. ENDANG BUDIARTI
Semnas dan Workshop

Sekolah Tinggi Ilmu Kesehatan Nasional
Swiss Bellin Hotel, Solo 7 April 2019
OUTLINES
• LATAR BELAKANG
• PERAN FARMASIS
• KASUS
L.ENDANG BUDIARTI 2
L.ENDANG BUDIARTI 3
Resistant bacteria of international concern
antibiotic MISUSE or OVERUSE or UNDERUSE
since microorganisms are constantly evolving resistance mechanisms
There have even been reports of resistance before some newer

antimicrobials have been approved for human use
2012 : 109 àphase 2 (31) à Phase 3 (9) à ?

Figure 3. Time lag between an antibiotic being introduced to
clinical use and the first appearance of resistance (27)
Resistant bacteria of international concern
Escherichia coli Resistance to third-generation cephalosporins;
Resistance to fluoroquinolones
Klebsiella pneumoniae Resistance to third-generation cephalosporins;
Resistance to carbapenems
Staphylococcus aureus Resistance to meticillin (MRSA)
Streptococcus pneumoniae Resistance, or non-susceptibility, to penicillin
Non-typhoidal salmonella (NTS) Resistance to fluoroquinolones
Shigella species Resistance to fluoroquinolones
Neisseria gonorrhoeae Decreased susceptibility to third-generation
cephalosporins
Enterococcus faecalis Resistance to vancomycin (VRE), to aminopenicillins
Pseudomonas aeruginosa Resistance to carbapenems, to amikacin, to
ceftazidime
Acinetobacter baumannii Resistance to carbapenems, to third-generation
cephalosporins
Masalah Penggunaan Antibiotik
• BAKTERI RESISTEN
• Missuse
• Overuse
• Underuse
• Mekanisme
• Efflux
•Degradation enz
• Altering enz
• Biofilm
L.ENDANG BUDIARTI 7
ESKAPE
• Enterococcus faecium (vancomycin-resistant enterococci : VRE).
• Staph aureus (methicillin-resistant Staphylococcus aureus :
MRSA).
• Klebsiella and Escherichia coli that are producing extended
spectrum beta-lactamases (ESBL) enzymes and carbapenemases.
• Acinetobacter baumannii.
• Pseudomonas aeruginosa.
• Enterobacter sp.
L.ENDANG BUDIARTI 8
L.ENDANG BUDIARTI 9
Risk Factors for Multidrug-Resistant Pathogens
Risk factors for MDR VAP
Prior intravenous antibiotic use within 90 d
Septic shock at time of VAP
ARDS preceding VAP
Five or more days of hospitalization prior to the occurrence of VAP
Acute renal replacement therapy prior to VAP onset
Risk factors for MDR HAP
Risk factors for MRSA VAP/HAP
Risk factors for MDR Pseudomonas VAP/HAP
L.ENDANG BUDIARTI 10
The solution to the current approaches to
antimicrobial resistance :
to preserve the effectiveness of the

drugs presently available by
antibiotic stewardship
to limit the spread of resistance

and to maximize hospital infection-
control practices,. (WHO)
Antimicrobial stewardship
Refers to coordinated interventions designed to improve and measure
the appropriate use of antimicrobials by promoting :
• the selection of the optimal antimicrobial drug regimen, dose,

duration of therapy, and route of administration.
https://www.idsociety.org/Stewardship_Policy/
Antimicrobial stewardship
• to achieve optimal clinical outcomes related to
antimicrobial use,
• minimize toxicity and other adverse events,
• reduce the costs of health care for infections, and
• limit the selection for antimicrobial resistant
strains.
https://www.idsociety.org/Stewardship_Policy/
ANTIBIOTIK BIJAK
GLOBAL ACTION
PLAN
• Optimize the use of antimicrobial
medicines in human and animal
health
REGULASI
Tahap : penggunaan antibiotiK bijak
a. meningkatkan pemahaman dan ketaatan staf medis fungsional dan tenaga
kesehatan dalam penggunaan antibiotik secara bijak
b. meningkatkan peranan pemangku kepentingan di bidang penanganan penyakit
infeksi dan penggunaan antibiotik
c. mengembangkan dan meningkatkan fungsi laboratorium mikrobiologi dan
laboratorium penunjang lainnya yang berkaitan dengan penanganan penyakit
infeksi
d. meningkatkan pelayanan farmasi klinik dalam memantau penggunaan antibiotik
e. meningkatkan pelayanan farmakologi klinik
f. meningkatkan penanganan kasus infeksi secara multidisiplin dan terpadu;
g. surveilans pola penggunaan antibiotic
h. surveilans pola mikroba penyebab infeksi dan kepekaannya terhadap antibiotik
INDIKATOR MUTU
• Perbaikan kuantitas penggunaan antibiotic
• Perbaikan kualitas penggunaan antibiotic
• Perbaikan pola sensitifitas antibiotic dan penurunan
microba multiresisten (pola kepekaan kuman)
• Penurunan angka infeksi rs
• Peningkatan mutu penanganan kasus infeksi multidisiplin
To prevent AMR and to reverse AMR rates
“Green pharmacy practice”
that pharmacists should accept a degree of

responsibility for changing the entire
medication-use process so as to minimise the
environmental effects of prescribing,
dispensing, pharmaceutical care, disposal of
unused medicines and, ultimately, reducing
metabolic waste discharge into the
environment
• Antibiotic use in hospitals is a main driver for the spread of multidrug-
resistant bacteria responsible for health care associated infections
• Other factor to AMR
• irresponsible use of medicines
• Effective antimicrobial drugs are prerequisites for both preventive and

curative measures
• Reducing AMR requires

• global action,
• education and
• promotion
• Guidelines and policies
Education for patients
• on antimicrobial use
• the importance of adherence to prescribed treatments,
• to ensure :
• patients receive medicines appropriate to their clinical needs
• at doses that meet their individual requirements
• for an adequate period and
• at the lowest cost to them and their community
Pharmacist - policy
• selection
The role in • procurement
• distribution
• Infection prevention
Contribute to • Infection control
• surveillance
improving • Prescribing
• Use of antimicrobial
March 2015, the American Pharmacists Association (APhA)
1. APhA supports the role of pharmacists in antimicrobial

stewardship in all practice settings.
2. APhA supports pharmacists working in collaboration

with others to lead the development and implementation
of antimicrobial stewardship programs and initiatives.
3. APhA supports pharmacists advising prescribers and

educating patients on the appropriate use of
antimicrobials.
The UK Pharmacy Infection Network (PIN) The Society of Hospital Pharmacists of Australia (SHPA)
Community pharmacists fighting AMR
• often the first point of contact for the public and they have a pivotal role in
• advising patients on minor ailments and
• referring them to their physician when required.
• They are often the entry gate to the health system on account of their easy
accessibility
• pharmacists :
• to offer an effective medication therapy management
• counselling on consumption of medicines
• engage patients in their appropriate, efficacious, safe and responsible use, as well as
consulting and collaborating with physicians to ensure optimal and responsible use
of antibiotics.
Community pharmacists fighting AMR
• health promotion and infection minimisation or control, triage and

optimal treatment management
• helping to reduce the need for use of antimicrobials
• correcting the misconception that antibiotics are needed to treat colds and
other minor ailments
• advice on how to overcome infections, including common viral
infections
• the Pharmaceutical Group of the European Union (PGEU),
• its statement “Community pharmacists’ contribution to the control of
antibiotic resistance”
Infection prevention and control
• educating the community on :
• hand washing
• hygiene practices,
• correct sneezing/coughing protocols,
• isolation of infected patients
• Effective prevention of infections transmitted
• safe sex or drug injection
• better sanitation,
• food and water safety
• The Scottish Antimicrobial Prescribing Group (SAPG) has developed a plan, “Self help guide to treating your
infection”
• In Canada, a public education programme called “Do bugs need drugs?” focuses on community education
about hand washing for infection prevention to stay healthy and stop the spread of the infection.
TRIAGE
• Appropriate treatment of symptoms without antimicrobials

• Direct supply of antimicrobials by pharmacists (ex: Canada, New
Zealand, UK)
• Referral to appropriate health professionals
• After an accurate assessment, pharmacists can offer to treat minor health
problems or infections with an over-the-counter medicine.
• If a serious health problem is identified and the person needs to see a
physician or specialist, pharmacists refer the patient to an appropriate
professional.
Optimal treatment management à
Adherance support
üShort-term infections
üLong-term infections
üDirectly observed treatment supervised by pharmacists is the best option for
TB
üDOTS (72.6%)>SAT (self-administered TB treatment , Spain) 26.7%
üSpecific cases :
üchild-specific formulations
Minimising interactions :
Pharmacist advise on
how to use medicines correctly
• When, how to take medicines,
• the optimal timing in relation to meals.
adverse side effects
potential interactions with other medicines

Ensuring quality of medicines
vs Counterfeit medicines
• Counterfeit medicines : à increase AMR
• no therapeutic effect
• may even be toxic
• it is not in sufficient quantity
• Protect The integrity of the supply chain
• procure medical products only from reputable sources
• OTC
• Internet sales
• alert to differences in quality of packaging, labelling or leaflets and in physical
appearance of medicinal products
Hospital pharmacists fighting AMR
• Pharmacist-led stewardship programmes
• Sterilisation :
• pharmacists, with their training in microbiology and aseptic technique, are
competent in the functions sterilisation services are expected to perform
• Hygiene in hospitals (decrease VRE, C. Dificille)

• to promote the use of disposable gloves in hospitals
Pharmacist-led stewardship programmes
• Goal :
• To optimise antimicrobial prescribing
• To improve individual patient care
• To slow the spread of antimicrobial resistance
• Practices :
• to ensure antimicrobial guidelines are evidence based,
• that patients are reviewed daily :
• to stop treatment if appropriate or
• to de-escalate to less powerful antibiotics and
• that regular antimicrobial audits and reviews of antibiotic use are performed
• Pharmacists have a responsibility to assist in the war on antibiotic
resistance.
• They have the knowledge and resources at their fingertips to raise
awareness and to act.
• There are multiple opportunities for pharmacists to assist in this campaign.
• The recognition of pharmacists as key members of antibiotic stewardship
teams in health systems is a milestone in infectious-diseases pharmacy
practice.
• Community pharmacists have a critical role to play in combating antibiotic
resistance as front-line practitioners who can educate and vaccinate
patients
The goal of the global action plan is :
to ensure,
continuity of successful treatment and prevention of infectious diseases
with effective and safe medicines
that are quality-assured,
used in a responsible way,
and accessible to all who need them
The goal of the global action plan is
to ensure, continuity of successful treatment and
prevention of infectious diseases
effective and safe medicines
quality-assured
used in a responsible way
accessible to all who need them

WORLD HEALTH ASSEMBLY :
Global Action Plan on AMR – 5 objectives
1. to improve awareness and understanding of antimicrobial resistance
through effective communication, education and training;
2. to strengthen the knowledge and evidence base through surveillance
and research;
3. to reduce the incidence of infection through effective sanitation, hygiene
and infection prevention measures;
4. to optimize the use of antimicrobial medicines in human and animal
health;
5. to develop the economic case for sustainable investment that takes
account of the needs of all countries and to increase investment in new
medicines, diagnostic tools, vaccines and other interventions
• Inappropriate prescribing and dispensing can lead to their misuse and
overuse if
• medical staff lack up-to-date information,
• cannot identify the type of infection, yield to patient pressure to prescribe
antibiotics, or
• benefit financially from supplying the medicines.
• Inadequate hygiene and infection prevention and control in hospitals
help to spread infections.
• Hospital patients infected with methicillin-resistant Staphylococcus
aureus have a higher risk of dying than those infected by a non-
resistant form of the bacteria.
Immunization can reduce
antimicrobial resistance in three ways
1. Existing vaccines can prevent infectious diseases whose treatment
would require antimicrobial medicines;
2. Existing vaccines can reduce the prevalence of primary viral
infections, which are often inappropriately treated with antibiotics,
and which can also give rise to secondary infections that require
antibiotic treatment;
3. Development and use of new or improved vaccines can prevent
diseases that are becoming difficult to treat or are untreatable
owing to antimicrobial resistance
ASHP Statement : Pharmacist Role in Antimicrobial
Stewardship and Infection Prevention and Control
Promoting the
Reducing the Educating health
optimal use of
transmission of professionals,
antimicrobial
infections patients, public
agents
Promoting Optimal Use of Antimicrobial Agents
1.
Multidisciplinary • Antimicrobial-related patient care
collaboration
• Antimicrobial-use policies (dev restricted antimicrobial

2. Pharmacy and procedure)
Therapeutics
Commitee • The number and type of antimicrobial agent available
are appropriate
3. Operating • To assess the effectiveness of antimicrobial use policies

multidisciplinary throughout the health system
Clinical and
economic
• Generating and analyzing quantitative data
outcome
analyses
• To ensure the appropriatness microbial
Working with susceptibility test, timely manner
microbiology
lab • Compiling susceptibility report (annualy) à
guiding empirical therapy
Utilizing • To enhance surveillance, utilization and outcome

information report
technology • Dev decision support-tool
Facilitating
• Utilizing effective and efficient systems
safe
to reduce potential errors and adverse
medication
event
management
• antimicrobial dose and regimen alteration;
• streamlining and sequential therapy;
• discontinuation of antimicrobials;
• advice on and as a result of therapeutic drug
monitoring;
P&T •
•
automatic stop orders for antimicrobial prophylaxis;
restricted antimicrobials;
Guidelines : • empirical antimicrobials;
• approval of restricted antibiotics;
• assistance in interpretation of laboratory results;
• indication for use of specific antimicrobials;
• suggestion for ordering additional laboratory testing
and formal educational events.
42 L.ENDANG BUDIARTI
• Early treatment : within 48 hours from the
onset of symptom
• Duration : therapy should continue for a
minimum of 48 to 72 hours after the patient
becomes afebrile and should have no more
P&T than one or two syndrome associated signs of
Guidelines : clinical instability
• Clinical stability : temperature; HR; RR, BP, O2
Sat
• switch IVà oral : the patient is
haemodynamically stable and improving
clinically, is fully conscious, and able to ingest
43 oral medications.
L.ENDANG BUDIARTI
To ensure that therapeutics use of
antimicrobial result in optimal
selection Aiding in appropriate selection

dosing Optimal dosing regimen
• Rapid initiation
• De-escalation
• ADJUST DOSE
Monitoring Proper monitoring
Host factor
• Allergy or history of adverse drug reactions

• ✓ Age of patient
• ✓ Pregnancy
• ✓ Metabolic abnormalities
• ✓ Renal and hepatic function
• ✓ Concomitant drug therapy
• Concomitant disease
• Organt failure (Renal, Liver)
Drug Factor
• PK/PD
• Time dependent/consentration dependent
• Tissue penetration
• PK parameter
• Drug of choice, guidelines
• Drug interaction
• Drug combination
Concentration- Time-Dependent,
Time-Dependent Dependent Concentration-Enhanced
(with minimal or no PAE) (with PAE) (with PAE)
Beta-lactams Aminoglycosides Clarithromycin
Vancomycin Daptomycin Clindamycin
Fluoroquinolones Erythromycin
Metronidazole Linezolid
Azithromycin Streptogramins
Ketolides Tetracyclines
Tigecycline
PAE : Post Antibiotic Effect
ANTIBIOTIK PROPHYLAXIS
PROCEDURE PROPHYLAXIS ALTERNATE
RECOMMENDATION PROPHYLAXIS
Urologic surgery/procedures
Transrectal prostate biopsy1 Cefazolin Ciprofloxacin OR
Gentamicin
Transurethral surgery (e.g. TURP, TURBT, Cefazolin Gentamicin
ureteroscopy, cystouretoscopy)
Lithotripsy Cefazolin Gentamicin
Neurosurgery
Craniotomy, cerebrospinal fluid-shunting Cefazolin Clindamycin
procedures, implantation of intrathecal pumps
Laminectomy Cefazolin Clindamycin
ANTIBIOTIK SOLUBILITY
SURVEILANS POLA PENGGUNAAN ANTIBIOTIC
AUDIT KUALITAS DAN KUANTITAS ANTIBIOTIK
• AUDIT KUALITAS
• MELAKUKAN REVIEW REKAM MEDIS
• REVIEW DILAKUKAN OLEH > 1ORANG
• DITETAPKAN SPO
• VALIDASI
GYSSENS FLOW CHART
DURASI (III A, IIIB)
DOSIS (IIa)
INTERVAL (IIb)
INDIKASI (V) RUTE (IIc)
OBAT LEBIH EFEKTIF (IVA)

WAKTU (I)
ALTERNATIF KURANG TOKSIK (IVB)
ALTERNATIF LEBIH MURAH (IVC)

ALTERNATIF LEBIH SEMPIT (IVD)
CASE
• Bp 70 tahun, 60kg, dengan pneumonia, DM,
• TD: 130/70 mmHg, HR: 70x/mnt, RR; 23x/mnt, T; 38
oC,
• WBC: 18.000/mmk, ureum/creat : 45/2.3. GDS 330
mg/dL, HbA1C 8,
• K/S : P. aeroginosa, Thorax : gambaran bayangan
bilateral
• Levofloxacin 1x750mg infus selama 10 hari
• Simvastatin 1x20mg tab tiap malam
KATEGORI GYSSENS & MEERS KETERANGAN
KELENGKAPAN DATA VI +
INDIKASI V +
ALTERNATIF OBAT LEBIH EFEKTIF IV a _
ALTERNATIF OBAT KURANG TOKSIK IV b _
ALTERNATIF OBAT LEBIH MURAH IV c _

ALTERNATIF OBAT LEBIH SEMPIT JENDELA IV d _
TERAPI
DURASI LEBIH LAMA III a _
DURASI LEBIH CEPAT III b _
BENAR DOSIS II a _
BENAR INTERVAL WAKTU II b _
BENAR RUTE II c +
BENAR WAKTU PEMBERIAN I +
TIDAK KATEGORI I-VI 0
AUDIT KUANTITAS
• DDD : DEFINED DAILY DOSE (DOSIS RATA-RATA HARIAN UNTUK
INDIKASI TERTENTU PADA ORANG DEWASA )
• CONTOH :
• CEFTRIAXON : 1DDD = 2000 mg
• AMOXYCILLINE : 1DDD = 1000 mg
• PENGGUNAAN DI RUMAH SAKIT
• DDD/100 PATIENT-DAYS (BED-DAYS)
• PENGGUNAAN DI KOMUNITAS
• DDD/1000 PERSON-DAYS (INHABITANT-DAYS)
CONTOH :
CEFTRIAXON : 1DDD = 2000 mg

AMOXYCILLINE : 1DDD = 1000 mg
PASIE REJIMEN LOS TOTAL DDD

N (G)
1 CEFTRIAXON 1X2 g, 5 10 10 10/2
HARI
2 AMOXYCILLINE 3X500 mg, 15 15 15/1
10 HARI
TOTAL HARI 25 CEFTRI : 5
AMOX : 15
DDD (100px- days) CEFTRI 5/25 x 100 = 20
AMOX 15/25x100= 60
5 specific objectives
1. ASSESS • The scope potential harm
2. CREAT • A frame work for action (patients, healthcare, system)
3. DEVELOP • Guidance, materials, technology, tools
4. ENGAGE Adherence/Complience
• KEY stakeholder ad partner for awareness
5. EMPOWER
• PATIENT and carers to become actively involve in treatment
• EFFECTIVELY MANAGE THEIR MEDICATIONS
“Drugs don't work in patients who don't take them.”
C. Everett Koop, M.D.
Non-adherence to antibiotic therapy in patients visiting community
pharmacies
Fernandes M1, Leite A, Basto M, Nobre MA, Vieira N, Fernandes R, Nogueira P, Nicola PJ.
1.8%
RESISTEN 57.7%
2.34%
Int J Clin Pharm. 2014 Feb;36(1):86-91. doi: 10.1007/s11096-013-9850-4. Epub 2013 Oct 8.
Morisky 8-Item Medication Adherence (MMAS8)Questionnaire
Question Patient Answer (Yes/No)
Score Y=1; N=0
1. Do you sometimes forget to take your medicine?

2. People sometimes miss taking their medicines for reasons other than forgetting.
Thinking over the past 2 weeks, were there any days when you did not take your
medicine?
3. Have you ever cut back or stopped taking your medicine without telling your
doctor because you felt worse when you took it?
4. When you travel or leave home, do you sometimes forget to bring along your
medicine?
5. Did you take all your medicines yesterday?
6. When you feel like your symptoms are under control, do you sometimes stop
taking your medicine?
7. Taking medicine every day is a real inconvenience for some people. Do you ever
feel hassled about sticking to your treatment plan?
8. How often do you have difficulty remembering to takeL.ENDANG
all yourBUDIARTI
medicine? 61
no single strategy had any clear advantage over another and that
combined cognitive, behavioral, and affective interventions were more
effective than single interventions
(Roter DL, Hall JA, Merisca R, Nordstrom B, Cretin D, Svarstad B. Effectiveness of interventions to improve
patient compliance: a meta-analysis. Med Care 1998; 36: 1138–61 )
– tailor the treatment to the patient’s lifestyle, not the other way round
George J, Shalansky SJ. Predictors of refill non-adherence in patients with heart failure. Br J Clin Pharmacol
2007; 63: 488–93
The AIDES Method for improving ADHERANCE
to medication
A: Assessment à asses all medication
I: Individualization à individualize the regimen
D: Documentation à provide written communication
E: Education à provide accurate and continuing education tailored
to the needs of individual
S: Supervision àprovide continuing of supervision of the regimen
Bergman-Evans B. AIDES to improving medication adherence

in older adults. Geriatr Nurs 2006; 27: 174–82
KOMPREHENSIF MULTIDISIPLIN
FOKUS
INDIKATOR
Kasus 1
• Seorang Ibu 89 th (40kg) datang ke rumah sakit kembali dengan keluhan
batuk, sesek. Tujuh hari sebelum masuk rumah sakit, pasien batuk disertai
banyak dahak berwarna hijau abu-abu dan susah dikeluarkan. Dilakukan
pemeriksaan darah rutin, foto thorax dan pemeriksaan sputum.
• TD: 140/100 mmHg, nadi: 117 x/menit. Respirasi: 24 x/menit. Suhu: 37.8 0C.
• Sp.O2 96%. Ureum : 79 mg/dl, creat 1.9mg/dl
• Hasil Lab : Hb 11 , Lekosit 21.000 /mm3, Hct 34, Trombosit 225.000
• Ro: Bronchopneumoni kiri kanan bawah, atelektasis subsegmental kanan bawah dan
efusi pleura kiri kanan minimal
• Pasien dengan riwayat DM dan alergi Ciprofloxacin, Claritromycin, Antalgin,
Penisilin
• Riwayat pengobatan sebelumnya :
• Clindamycin tab 3 x 300 mg dan Cotrimoxazole Forte tab 2 x 960 mg
• Pada pemeriksaan sputum didapati : Klebsiela pneumonia, P. aeroginosa
PATOGENESIS PNEUMONIA
DIAGNOSIS (PDPI)
Menurut kriteria dari The Centers for Disease Control (CDC-Atlanta),

diagnosis pneumonia nosokomial adalah sebagai berikut :
1. Onset pneumonia yang terjadi 48 jam setelah dirawat di rumah sakit
dan menyingkirkan semua infeksi yang inkubasinya terjadi pada waktu
masuk rumah sakit
2. Diagnosis pneumonia nosokomial ditegakkan atas dasar :
• Foto toraks : terdapat infiltrat baru atau progresif
• Ditambah 2 diantara kriteria berikut:- suhu tubuh > 38o C - sekret
purulen - leukositosis
Guidelines for the management of hospitalised adults patients with pneumonia in the Asia Pacific region. 2nd Concensus Workshop. Phuker, Thailand 1998.
Kelompok I :
Kuman penyebab : Enterobacter spp, E coli, Klebsiella spp, Proteus spp,
S.marcescens,H.Influenzae,
S.pneumoniae, S.aureus
Kelompok II :
Kuman penyebab utama : Enterobacter spp, E.coli,Klebsiella spp, Proteus spp,
S.marcescens, H.Influenzae, S.pneumoniae, S.aureus (Hati-hati kemungkinan ada MRSA)
Kuman penyebab tambahan : anaerob, MRSA, legionella spp, P.aeruginosa
Kelompok III :
Kuman penyebab utama : Enterobacter spp, E coli, Klebsiella spp, Proteus spp,
S.marcescens,H.Influenzae, S.pneumoniae, S.aureus (hati-hati kemungkinan ada MRSA)
Kuman penyebab tambahan : P.aeruginosa, acinetobacter Spp, S.maltophilia, MRSA
Harus dipikirkan kemungkinan terdapat infeksi P.aeruginosa atau

acinetobacter atau MRSA. Pada keadaan ini diperlukan agresif pengobatan
antibiotika kombinasi. L.ENDANG BUDIARTI 69
Table 4. Recommended Initial Empiric Antibiotic Therapy for Hospital-Acquired Pneumonia
(Non-Ventilator-Associated Pneumonia)
Rejimentasi antibiotic ?
• Faktor penyakit :
• Faktor Host :
• Faktor Organ :
• Faktor Obat :
S
Susceptibility Isolate 1 Isolate 2
ISOLATE 1 : Klebsiella pneumoniae

Cefazolin R
Ceftriaxone R
Gentamycin S R
Amikacin S S
S : Gentamicin, Amikacin, Netilmicin, Netilmicin
Ampicillin-Sulbactam
S
R
I
Piperacillin-Tazobactam, Ceftazidim, Amox.+Clavulanic Acid
Piperacillin/Tazobactam
R
S
R
Cefipime, Cefpirom, Doripenem, Ceftizoxime
Cefuroxime
R
R
R
Norfloxacin, Ciprofloxacin, Cefotaxime
Ceftazidime S
R
Levofloxacin Cefepime
Cefpirome
S
S
R
Fosfomycin R R
Co-trimoxazole R R
ISOLATE 2 : Pseudomonas Tigecycline
Nitrofurantonin
R
R
S
aeruginosa Aztreonam R R
Kanamycin R R
Doripenem S S
S : Amikacin, Piperaacillin-
Ertapenem S
Meropenem R S
Tazobactam, Nitrofurantoin,
Ampicillin R R
Amoxicillin R
Tigecyclin, Doripenem, Ertapenem,

Norfloxacin S R
Ciprofloxacin S I
Meropenem, Levofloxacin Levofloxacin

L.ENDANG BUDIARTI
Tetracycline
S
R
S
R
74
XVI. Which Antibiotic Should Be Used to Treat Patients With HAP/VAP Due
to P. aeruginosa? Recommendations
1. Forpatients with HAP/VAP due to P. aeruginosa, we recommend

that the choice of an antibiotic for deﬁnitive(not empiric) therapy
be based upon the results of antimicrobial susceptibility
testing(strong recommendation,low-quality evidence).
2. For patients with HAP/VAP due to P.aeruginosa, we recommend
against aminoglycoside monotherapy (strong recommendation,
very low-quality evidence). Remarks: Routine antimicrobial
susceptibility testing should include assessment of the sensitivity of
the P. aeruginosa
XVII. Should Monotherapy or Combination Therapy Be Used to Treat
Patients With HAP/VAP Due to P. aeruginosa? Recommendations
• For patients with HAP/VAP due to P.aeruginosa,

we recommend against aminoglycoside monotherapy (strong
recommendation, very low-quality evidence).

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Peran Apoteker - MDR

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Peran Farmasis dalam Menghadapi

Penyebaran Resistensi Antimikroba dan

Semnas dan Workshop

since microorganisms are constantly evolving resistance mechanisms

There have even been reports of resistance before some newer

2012 : 109 àphase 2 (31) à Phase 3 (9) à ?

to preserve the effectiveness of the

to limit the spread of resistance

• the selection of the optimal antimicrobial drug regimen, dose,

that pharmacists should accept a degree of

• Effective antimicrobial drugs are prerequisites for both preventive and

• Reducing AMR requires

1. APhA supports the role of pharmacists in antimicrobial

2. APhA supports pharmacists working in collaboration

3. APhA supports pharmacists advising prescribers and

• health promotion and infection minimisation or control, triage and

• Appropriate treatment of symptoms without antimicrobials

adverse side effects

potential interactions with other medicines

• Hygiene in hospitals (decrease VRE, C. Dificille)

effective and safe medicines

used in a responsible way

accessible to all who need them

• Antimicrobial-use policies (dev restricted antimicrobial

3. Operating • To assess the effectiveness of antimicrobial use policies

Utilizing • To enhance surveillance, utilization and outcome

selection Aiding in appropriate selection

Monitoring Proper monitoring

• Allergy or history of adverse drug reactions

INDIKASI (V) RUTE (IIc)

OBAT LEBIH EFEKTIF (IVA)

ALTERNATIF LEBIH MURAH (IVC)

ALTERNATIF OBAT LEBIH MURAH IV c _

CEFTRIAXON : 1DDD = 2000 mg

PASIE REJIMEN LOS TOTAL DDD

1. ASSESS • The scope potential harm

2. CREAT • A frame work for action (patients, healthcare, system)

3. DEVELOP • Guidance, materials, technology, tools

1. Do you sometimes forget to take your medicine?

Bergman-Evans B. AIDES to improving medication adherence

Menurut kriteria dari The Centers for Disease Control (CDC-Atlanta),

Harus dipikirkan kemungkinan terdapat infeksi P.aeruginosa atau

ISOLATE 1 : Klebsiella pneumoniae

S : Gentamicin, Amikacin, Netilmicin, Netilmicin

Piperacillin-Tazobactam, Ceftazidim, Amox.+Clavulanic Acid

Cefipime, Cefpirom, Doripenem, Ceftizoxime

Norfloxacin, Ciprofloxacin, Cefotaxime

ISOLATE 2 : Pseudomonas Tigecycline

Tigecyclin, Doripenem, Ertapenem,

Meropenem, Levofloxacin Levofloxacin

1. Forpatients with HAP/VAP due to P. aeruginosa, we recommend

• For patients with HAP/VAP due to P.aeruginosa,

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