Dr. Ronald Irwanto Natadidjaja, SPPD - Kpti, Finasim: Pendidikan

Curriculum Vitae
Nama : Dr. Ronald Irwanto Natadidjaja, SpPD – KPTI, FINASIM
Pendidikan :
SMP - SMA : Kolese KANISIUS, lulus 1994
Dokter Umum : FK TRISAKTI, lulus 2002
Spesialis Penyakit Dalam (Internist) : FKUI, lulus 2009
Konsultan Penyakit Tropik & Infeksi : FKUI / PAPDI, lulus 2013
Pekerjaan :
Bendahara Pengurus Besar Perhimpunan Konsultan Penyakit Tropik dan Infeksi Indonesia (PB PETRI)
SekJen Pengurus Pusat Perhimpunan Pengendalian Infeksi Indonesia (PP. PERDALIN)
Tim Panel Ahli PNPK Sepsis, Kemenkes RI
Anggota Pokja PPI, Kemenkes RI
Kepala Bagian Ilmu Penyakit Dalam, FK TRISAKTI
Ketua PPRA, RS PONDOK INDAH – PURI INDAH dan RS PONDOK INDAH – BINTARO JAYA
Wakil Ketua Komite Medik, RS PONDOK INDAH – PURI INDAH
Internist - Konsultan, RS PONDOK INDAH – PURI INDAH dan RS PONDOK INDAH – BINTARO JAYA
Ronald Irwanto Antimicrobial Stewardship Program (RASPRO) Indonesia
RASPRO Antibiogram Validation and Setting
Ronald Irwanto
Infectious Disease (ID) Specialist
RASPRO INDONESIA
ANTIMICROBIAL STEWARDSHIP
PROGRAM
PRE-AUTHORIZATION Post Antibiotic Review

RESTRICTION vs NON RESTRICTION
- Person vs System
- AB Classification vs AB Guidelines
(A,B,C)
Ronald Irwanto, 2017

PINK BOX PURPLE BOX PEACH BOX
1. Promoting Guidelines (3) 2. Implementation (3) : 3. Evaluation (3) :

1. Disease Severity and 1. Strengthening Knowledge 1. Host :
Risk (Carmeli Conclusion) 1. Workshop 1. Hospital Stay
1. Type 1 2. Socialization 2. Cost
2. Type 2 3. Discussion 3. Mortality
3. Type 3 2. Controlling the Socio-Behavioral 2. Agent :
2. Antibiotic PK/PD 1. Credential 1. MDR-HAIs Incidence
1. Dose 2. Re-credential 2. Patient Colonization
2. Track 3. Restriction Program / 3. Environment
Consultation Regulation Colonization
3. Tissue Penetration
3. Information Technology (IT) 3. Compliance :
3. Microorganism Pattern
1. Guidelines breakdown 1. Define Daily Dose
1. Layer 1 : 3 T
(Quantitative)
1. Timing 2. Socialization for using
2. Technique 3. Guidance & Discussion
2. Gyssens
3. Transport
(Qualitative)
2. Layer 2 : 3 C
1. CLSI THE RULE of 3 PIE 3. Case Report
2. Completing plate
(Sporadic)
3. Completing MIC-90
Ronald Irwanto Antimicrobial
3. Layer 3 : 3 P
Stewardship Program (RASPRO) File
1. Proper Setting
RSPI-PURI INDAH
2. Proper Size
Copyright
3. Proper Percentage
PROMOTING GUIDELINES
1. Disease Severity and Risk
Microorganism Pattern
(Carmeli Conclusion)
1. Layer 1 : 3 T
1. Type 1
1. Timing
2. Type 2
2. Technique
3. Type 3
3. Transport
2. Antibiotic PK/PD
1. Dose
2. Track 2. Layer 2 : 3 C
3. Tissue Penetration 1. CLSI
3. Microorganism Pattern 2. Completing plate
1. Layer 1 : 3 T 3. Completing MIC-90
1. Timing
2. Technique
3. Transport 3. Layer 3 : 3 P
2. Layer 2 : 3 C 1. Proper Setting
1. CLSI 2. Proper Size
2. Completing plate 3. Proper Percentage
3. Completing MIC-90
3. Layer 3 : 3 P
1. Proper Setting
2. Proper Size
3. Proper Percentage
Ronald Irwanto, RASPRO Indonesia, 2018
3T TIMING
Standard Operating Procedure : Sample taking before
antibiotics administered (for Community Setting ) or in
fulfilled diagnosis (HAIs)
TECHNIQUE
Sample handling within standard
TRANSPORT
Transport Procedure within standard
3C
Choosing Standard for Examinanation
Sensitivity Test Done by CLSI / EUCAST
Line 1, 2, 3Done as a protocol
Completing Plate
Plate should be complete served
Completing MIC-90
R/S defined best by MIC-90
MIC-90
3P
Proper Setting
Restriction Policy Setting VS Antibiotic Guidelines Setting
Community Setting VS Hospital Setting
Proper Size
n ≥ 30 for each microorganism
Proper Percentage
Percentage for describing the sensitivity in well counting procedure
3TCP False Report

• High Resistance Result
• Colonization Result
• Invalid Result
• Non Representative Result
• Lack of Accuracy Result
• Needs Inappropriate Result

3T MISS
• TIMING
MISS HIGH RESISTANCE
RESULT
• TECHNIQUE MISS COLONIZATION

RESULT
• TRANSPORT MISS COLONIZATION

RESULT

3C MISS
MISS INVALID
• CLSI
RESULT
• Completing MISS Non Representative

Plate RESULT
MISS Lack of Accuracy

• Completing
RESULT??
MIC
3P MISS
• Proper MISS Needs Inappropriate
RESULT
Setting
MISS Non Representative

• Proper Size RESULT
MISS Non Repersentative

• Proper
RESULT
Percentage
Proper Setting
Restriction Policy Setting Antibiotic Guidelines Setting
Gram (+)ve AB AB AB AB AB AB AB Sputum Gram (+)ve AB AB AB AB AB
S.pneumoniae
S.aureus
S.aureus
S.Epidermidis Gram (-)ve
S.B- hemoliticus Klebsiela sp
Pseudomonas sp
Acinetobacter sp
Gram (-)ve
Urine Gram (+)ve
E.Coli S.faecalis
Klebsiela sp
Gram (-)ve
Pseudomonas sp E.coli
Acinetobacter sp Pseudomonas sp
Acinetobacter sp

• Defining the Broad and the

Narrow Spectrum!!!
Antibiogram :
Defining the Spectrum Cut Off
GRAM POSITIVE
Broad Spectrum for gram positive :

Antibiotic for eradicating MDR Gram Positive :
Such as
Methicillin Resistant Staphylococcus Aureus / Epidermidis
(MRSA / E),VRE :
Glikopeptide : Vancomycin and Teicoplanin
Oxazolindinone : Linezolid

Defining the Spectrum Cut Off

GRAM NEGATIVE
First Cut Off: Extended Spectrum Beta-Lactamase ( ESBLs)
based cut off
• ESBLs based cut off sebenarnya adalah cut off PERTAMA yang digunakan untuk
pemisahan antibiotik spektrum luas atau sempit.
• ESBL based cut off sebenarnya agak sukar ditentukan, karena banyak rumah sakit
yang tidak dapat memisahkan kuman-kuman ESBLs dalam Pelaporan pola
kumannya.
• Namun jika keterangan pemisahan kuman ESBLs tersebut ada dan dapat
digunakan cut off nya, maka hal tersebut dapat digunakan sebagai dasar restriksi
antibiotik.
• ESBLs based cut off dapat digunakan pada kondisi-kondisi dimana Multi-Drug
Resistant (MDR) Pseudomonas sp dan / atau MDR / XDR Acinetobacter sp belum
banyak didapatkan.
GRAM NEGATIVE
Second Cut Off : Pseudomonas sp based cut off
• Pseudomonas based cut off digunakan sebagai cut off KEDUA yang
digunakan pemisahan antibiotik spektrum luas atau sempit.
• Pseudomonas based cut off dapat digunakan sebagai dasar
informasi untuk melakukan restriksi antibiotik yang masih sensitif
dan dapat digunakan untuk eradikasi kuman-kuman MDR
Pseudomonas sp.
• Pseudomonas based cut off umumnya digunakan ketika telah
banyak dijumpai ESBL di rumah sakit, dimana ESBL based cut off
tidak lagi bisa digunakan sebagai cut off untuk menentukan
antibiotik spektrum luas atau sempit.
Gram NEGATIVE
Third Cut Off : Acinetobacter sp based cut off
• Acinetobacter based cut off digunakan sebagai cut off KETIGA yang
digunakan pemisahan antibiotik spektrum luas atau sempit.
• Acinetobacter based cut off dapat digunakan sebagai dasar informasi
untuk melakukan restriksi antibiotik yang masih sensitif terhadap
kuman-kuman MDR / XDR Acinetobacter sp.
• Acinetobacter based cut off umumnya digunakan ketika telah banyak
dijumpai MDR Pseudomonas di rumah sakit, dimana Pseudomonas
based cut off tidak lagi bisa digunakan sebagai cut off untuk
menentukan antibiotik spektrum luas atau sempit.
Microorganism Based Report for Restriction

Org Organism No. AMK AMP SAM ATM MEM CTX CAZ CRO CIP
eco E.coli 164 95.4 23.5 89.3 15.3 100 78.8 98.5 88.7 80.5
kpn K.pneumoniae 143 96.7 34.5 78.9 56.7 100 89.8 94.5 83.3 88.2
ecl E.cloacae 73 93.3 23.3 80.8 40.5 100 78.3 91.1 77.7 100
aba A.baumannii 62 74.3 11.1 24.4 10.1 88.9 15.4 15.4 12.3 75
pae P.aeruginosa 55 85.4 15.3 15.1 10.3 90.1 45.3 80.9 15.2 50
Free to Use : PLUS
Ceftriaxone Vancomycin,
Cefotaxime Teicoplanin
Under Supervision (Restriction) Linezolid
Ampicillin Sulbactam
Amoxycillin Clavulinic Acid Tigecyclin
Ertapenem Polymixin
Restriction :
Meropenem, Carbapenem II Pseudomonas based cut off 80
Ceftazidime
Ciprofloxacin
Acinetobacter based cut off 70
Amikasin Ronald Irwanto, RASPRO Indonesia, 2018
Cefepime, Cefpirome
URINE SPECIMEN
Specimen Based Report for Gudelines Making
eco E.coli 164 95.4 23.5 89.3 15.3 100 78.8 98.5 88.7 80.5
kpn K.pneumoniae 143 96.7 34.5 78.9 56.7 100 89.8 94.5 83.3 88.2
ecl E.cloacae 73 93.3 23.3 80.8 40.5 100 78.3 91.1 77.7 100
aba A.baumannii 62 74.3 11.1 24.4 10.1 88.9 15.4 15.4 12.3 75
pae P.aeruginosa 55 85.4 15.3 15.1 10.3 90.1 45.3 80.9 15.2 50
ANTIBIOTIC For UTI

Strat Risk I
Strat Risk II Ronald Irwanto, RASPRO Indonesia, 2018
Strat Risk III
POLA KUMAN dari SPESIMEN URINE

eco E.coli 164 95.4 23.5 89.3 15.3 100 78.8 98.5 88.7 80.5
kpn K.pneumoniae 143 96.7 34.5 78.9 56.7 100 89.8 94.5 83.3 88.2
ecl E.cloacae 73 93.3 23.3 80.8 40.5 100 78.3 91.1 77.7 100
aba A.baumannii 62 74.3 11.1 24.4 10.1 88.9 15.4 15.4 12.3 75
pae P.aeruginosa 55 85.4 15.3 15.1 10.3 90.1 45.3 80.9 15.2 50
ANTIBIOTIK dengan Penetrasi baik ke Saliuran Kemih
Golongan Penicillin :
Amoxycillin, Ampicillin, Amoxycillin Clavulanat, Ampicillin Sulbactam, Piperacillin Tazobactam
Golongan Cephalosporin :
Cephalosporin gen. III dan IV
Golongan Quinolon :
Ciprofloxacin
Golongan Carbapenem :
Ertapenem, Imipenem, Meropenem
Golongan lain :
Fosfomycin, Cotrimoxazole, Amikacin
Cunha et al
UTI Strat.Type I : Ceftriaxone Alternatif :

Cefotaxime Amoxycillin / Ampicillin
Ceftazidime Cefixime, Cotrimoxazole
Antibiotic Ciprofloxacin
Guidelines ?? Amikasin
UTI Strat.Type II : Ampicillin Sulbactam

/ Ertapenem
Individu berisiko infeksi ESBL
Meropenem +/- Ciprofloxacin
UTI Strat.Type III : / Amikasin
Individu berisiko infeksi MDR
ATAU
Ceftazidime /Cefepime / Cefpirome +/- Ciprofloxacin / Amikacin
POST -AB REVIEW MODEL : GUIDELINES PRE AUTHORIZATION MODEL :
RESTRICTION
Stratification Type I : Free to Use :
Pilihan : Ceftriaxone, Cefoperazone
Ceftriaxone / Cefotaxime Cefotaxime
Alternative :
Cefixime / Amoxycillin / Ampicillin
ATAU
Under Supervision :
Cotrimoxazole Ampicillin-Cefo Sulbactam
Amoxycillin Clavulinic Acid
Stratification Type II Ertapenem
ATAU
Ertapenem
Restriction : PLUS
Stratification Type III : Meropenem Vancomycin,
Meropenem +/- Ciprofloxacin / Amikacin Ceftazidime Teicoplanin
ATAU Ciprofloxacin Linezolid
Ceftazidime/ Amikasin, Tigecyclin
Cefepime / Cefpirome +/- Ciprofloxacin
/ Amikacin Cefepime, Cefpirome Polymixin
Proper Setting
Community Setting Hospital Setting
Sputum Gram (+)ve AB AB AB AB AB Sputum AB AB AB AB AB
S.pneumoniae
S.aureus Gram (-)ve
E.coli
Gram (-)ve Klebsiela sp
Klebsiela sp Pseudomonas sp
Pseudomonas sp Acinetobacter sp
Acinetobacter sp
Urine Gram (+)ve Urine Gram (+)ve

S.faecalis S.faecalis
Gram (-)ve Gram (-)ve

E.coli E.coli
Pseudomonas sp Pseudomonas sp
Acinetobacter sp Acinetobacter sp

Hospital Setting
• HAP/VAP
• SSI
• CAUTI
• CR-BSIs
Every diagnosis above (+)ve Sample Taking
Antibiogram Validation Chart : 3 TCP (RASPRO)
1
3-T
Timing is Correct : Taking before Antibiotics
Yes No
2 Technique is within Standard

3 Transport is within Standard
3-C
1 Choosing Standard for examination (CLSI / EUCAST)
2 Completing Plate
3 Completing MIC-90
1
3-P
Proper Setting
2 Proper Size
3 Proper Percentage
RASPRO Chart, Ronald Irwanto, 2017
THANK YOU
www.rasproindonesia.com

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Dr. Ronald Irwanto Natadidjaja, SPPD - Kpti, Finasim: Pendidikan

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Curriculum Vitae

Nama : Dr. Ronald Irwanto Natadidjaja, SpPD – KPTI, FINASIM

SekJen Pengurus Pusat Perhimpunan Pengendalian Infeksi Indonesia (PP. PERDALIN)

Tim Panel Ahli PNPK Sepsis, Kemenkes RI

Anggota Pokja PPI, Kemenkes RI

Kepala Bagian Ilmu Penyakit Dalam, FK TRISAKTI

Wakil Ketua Komite Medik, RS PONDOK INDAH – PURI INDAH

RASPRO Antibiogram Validation and Setting

PRE-AUTHORIZATION Post Antibiotic Review

Ronald Irwanto, 2017

1. Promoting Guidelines (3) 2. Implementation (3) : 3. Evaluation (3) :

3TCP False Report

Ronald Irwanto, RASPRO Indonesia, 2018

• TECHNIQUE MISS COLONIZATION

• TRANSPORT MISS COLONIZATION

Ronald Irwanto, RASPRO Indonesia, 2018

• Completing MISS Non Representative

MISS Lack of Accuracy

MISS Non Representative

MISS Non Repersentative

Ronald Irwanto, RASPRO Indonesia, 2018

• Defining the Broad and the

Broad Spectrum for gram positive :

Ronald Irwanto, RASPRO Indonesia, 2017

Defining the Spectrum Cut Off

Microorganism Based Report for Restriction

ANTIBIOTIC For UTI

POLA KUMAN dari SPESIMEN URINE

UTI Strat.Type I : Ceftriaxone Alternatif :

UTI Strat.Type II : Ampicillin Sulbactam

Urine Gram (+)ve Urine Gram (+)ve

Gram (-)ve Gram (-)ve

Ronald Irwanto, RASPRO Indonesia, 2018

Antibiogram Validation Chart : 3 TCP (RASPRO)

2 Technique is within Standard

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