Antimicrobial Resistance Control Program

(ARCP) : implementing in

Dr. Cipto Mangunkusumo Hospital

Khie Chen

Antimicrobial Resistance Controlling Program

Department of Internal Medicine

Dr. Cipto Mangunkusumo Hospital

Jakarta

Current Problem in Antibiotics Use

Increasing Resistance Problems

Limited new antibiotics in pipelines

How to use antibiotics appropriately?

Infection Major pathogen Major

resistance

Urinary tract

infection

E. coli, K.

pneumoniae

Enterococci

ESBL

VRE

Pneumonia P. aeruginosa

A. baumanni

MDR/PDR/XD

R

Surgical site

infection S. aureus MRSA

Bloodstream

infection

Coagulase(-)

Staphylococci

S. aureus

MR-CNS,

MRSA

(UTI)

(Gastroenteritis)

Infectious diagnosis in Internal Medicine Ward Apr-Jun 2010

1. Establish national infection control programs :

National programs to control antimicrobial resistance (ARCP/PPRA) since 2005

2. Establish effective, hospital-based therapeutics committees for monitoring antimicrobial usage

3. Develop and regularly update on guidelines for antimicrobial usage, especially on treatment & prophylaxis

4. Ensure access to microbiology labs

(National Programe)

Dr. Cipto Mangunkusumo Hospital

National General Hospital

Teaching Hospital

Class : A

Owner : Ministry of Health – Indonesia

Address : Jl. Diponegoro No. 71, Jakarta

Number of bed : 1220

Department/unit : 32

Internal Medicine Department

Regular Bed 100

(Male 53, Female 47)

Bed in Isolation Ward

(for immunocompromised patient) 24

Bed for HIV/AIDS Patient 6

Bed in High Care Unit 4

Total 134

Divisions in Internal Medicine

Department

Metabolic and

Endocrinology

Kidney and Hypertension

Gastroenterology

Rheumatology

Medical Hematology and

Oncology

Psychosomatic

Tropical and infectious

Disease

Pulmonology

Geriatry

Clinical Allergy and

Immunology

Cardiology

Hepatology

Antimicrobial Resistance Controlling

Programe

Hospital policy of Antimicrobial Usage

Antimicrobial Resistance Controlling Programe

- Decreasing Antimicrobial Resistance

.

•

IDSA/SHEA. Guidelines for developing an instutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44: 159–77.

Aims

Decreasing total use of antibiotics (quantitative)

Increasing appropriate use of antimicrobial

(qualitative)

IDSA/SHEA. Guidelines for developing an instutional program to

enhance antimicrobial stewardship.. Clin Infect Dis 2007; 44: 159–77.

Nosoco

mial Infection

Committe

Pharmacist Clinical

Microbio logist

Clinical Pharmaco

logist

ARCP

Dept

Dept Dept

Dept

Dept Dept

Dept

Dept

Colaborative of ARCP

Decree of Director of CM Hosp:

7139/TU.K/34/VII/2009

deciding:

Formation of Antimicrobial Resistance

Controlling Program

(ARCP/PPRA)

Pharmacy and

Therapeutic

Committe

ARCP

Hospital and

Department

Team

Collaborative working system of

ARCP

Clinical Pharmacist Nosocomial Infection

Committe

Clinical

Microbiologist

Hospital Director REPORT

Working Task of ARCP Team

Deciding hospital regulation of antimicrobial resistance controling

Deciding policy of antimicrobial usage

Develop program of antimicrobial resistance controlling

Monitoring and evaluation of ARCP

Organizing discussion forum in managing infectious disease

(and antimicrobial usage auditing)

Socialization and education of appropriate antimicrobial usage for physician/users

Develop clinical researches related to ARCP

ARCP Team Internal Medicine Departement

Div Hepatology

Dr. Andri Sanityoso

Div Metabolic Endocrine

Dr. M. Yunir

Div Kindey Disesase and Hipertension

Dr. Pringodigdo

Div Gastroenterology

Dr. Marcell Simadibrata

Div Hematology& Clin Oncology

Dr. Ichwan Rinaldi

Div Rheumatology

Dr. Rudi Hidayat

Div Tropical Medicine &

Infectious Disease

Dr. Khie Chen, Dr. Erni J Nelwan

Div Pulmonology

Telly Kamelia

Div of Geriatri

Dr. Kuntjoro Harimurti

Div Allergy&Immunology

Dr. Evy Yunihastuti

Div Cardiology

Dr. Muhadi

Working Task of ARCP Internal Medicine

Develop Hospital Guidelines of antimicrobial usage

Perform socialization and education programe

Perform antimicrobial usage controlling programe in

Dept of Internal Medicine

Implementing antimicrobial auditing

Implementing antimicrobial surveillance

Developing Antimicrobial Usage Guidelines

Base on consensus

Existing national/international guidelines

Suggestion from the users, clinical microbiologist

Drug availability and cost

Practical guidelines and easy to perfom

Developing Antimicrobial Usage Guidelines

Make priority

a. Guidelines for antimicrobial prophylaxis

b. Guidelines for treatment

Most common infections in each department:

e.g. ICU : HAP/VAP

Internal Medicine : CAP, UTI, IAI, SSTI

Pediatric : URTI, LRTI, CNS infections

Surgery : Surgical prophylaxis, SSI

Hospital Antimicrobial

Guidelines Pattern/Stratification

1. Diseases Classification or stratification

e.g Pneumonia : CAP -- class I-IV

HAP – early onset : risk factor

-- late onset

2. Treatment approach : empirical

definite treatment

Guidelines Matrix example

Diagnos

is Diagnosis Terapi Empirik

Lama

terapi Mikroorganisme Terapi Definitif Dosis

Monoterapi Kombinasi

HAP

Cefuroxime

2x500 mg (oral) (cari

info injeksi 2x1 gr))

Pneumonia

Nosokomial (HAP)

early onset, tanpa

faktor risiko

(1) sefalosporin

generasi 2 (tanpa

antipseudomonas)

7 hari

Streptococcus

pneumonia Cefotaxime

1-2 gram setiap 8 jam

(2) sefalosporin

generasi 3 (tanpa

antipseudomonas)

Haemophilus

influenza Ceftriaxone

1-2 gram/hari

(maksimal 4

gram/hari)

(3) Fluoroquinolon

oral atau injeksi Klebsiella

pneumonia Ciprofloxacin (tunda)

3x400 mg (IV) 2x750

mg (oral)

Escherichia coli

Levofloxacin

1x750 mg (dapat

disesuaikan dengan

berat badan sekitar

1x500-750 mg) IV ;

1x750 mg (oral)

Enterobacter spp.

Moxifloxacin 400 mg/hari (IV) ;

400mg/hari(oral)

Proteus spp.

Ampicillin Sulbactam injeksi 3x1,5 gr

Serratia

marcescens Amoxiclav injeksi 3x1,5 gr

S.aureus (MSSA)

ARCP Socialization and Education

Clinical staff and clinical assistant meeting

Book/brochure and leaflets

Online : ppra-ilmupenyakitdalam.blogspot.com

Email : ppra-ipd@gmail.com

Portal akan memuat infomasi mengenai kebijakan dan Panduan serta antibiotik

yang digunakan dalam cycling dan mixing

Controlling of Antimicrobial Usage

Antibiotics in line I and II

Controlling base on antimicrobial hospital guidelines

Perfom antimicrobial cycling and mixing

Control by pharmacy

Pre authorization (approval): out of the guidelines

Antibiotics in line III

Need pre authorization

Empirical : critical condition and sepsis

Definite : base on microbiological culture results

Antimirobial groups classification

Line 1 Line 2 Line 3

Aminoglicoside

Penicillin

1st and 2nd gen Cef

Chloramphenicol

Fusidic acid

Lincosamide

Macrolide

Nitroimidazole

Fluroquinolone

1st and 2nd gen

Tetracyclien

TMP-SMX

Fosfomycin

3rd gen Cephalosporin

Fluroquinolone

gen 3rd and 4th

Amikacin

Teicoplanin3

Linezolide

Cefepime

Cefpirome

Carbapenem

Tygecycline

Ceftazidime

Pip-Tazo

Aztreonam

Vancomycin

Role of Microbiological Laboratory

Important to documented infections

Barier :

Lack of awareness the importance to collect

microbiological specimen before giving antibiotics.

Inappopriate procedure to collect the specimen.

Lack of knowledge interpreating the microbiological

results

If definite pathogen could be identified, narrow spectum antibiotic could be given.

Auditing

Periodically done by antibiotic team (multi

department), commissioned by management of

hospital

Audit of medical records, copy of prescriptions

Percentage of compliance to antibiotic guideline

Reward and punishment

Antibiotics auditing

Recording of antimicrobial usage

Quantitative audit : Pharmacy

Qualitative audit : Gyssen classification

Perform by ARCP Team, Clinical pharmacologist, clinical microbiologist

Evaluation of policy and antimicrobial guidelines

Feed back to physician/users

Yearly auditing report

Quanti tative audit

Defined Daily Dose (DDD): average dosage for adults

eg:

Tetracyline : 1 DDD = 1000 mg

Ampicillin : 1 DDD = 2000 mg

Amoxycillin : 1 DDD = 1000 mg

Ceftriaxone : 1 DDD = 2000 mg

Antimicrobial usage in hospital :

DDD/100 patient-days (bed-days)

Antimicrobial usage in community:

DDD/1000 person-days (inhabitant-days)

Evaluation category of

Antibiotics Usage by Gyssens

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

Antimicrobial quantitative data in Dept of

Internal Medicine April-Jun 2010

Data Penelitian di Departemen IPD April-Juni

2010 tingkat konsumsi AB : 170 DDD/100 bed

days (Dina Fauzia, Dept Farmakologi FKUI)

Computer Base Programe

Implementation

Computer base antimicrobial prescription

Computer base antimicrobial used recording

Computer base auditing and surveilans

Lack of awareness from hospital

committee/management about the importance and

urgency to implementing ARCP

Lack of personnel willing to spare time and effort to

develop and enforcing ARCP

Lack knowledge of personel how to start and

implementing ARCP

Difficulties to implementing antibiotic restrictions in term

of reducing the users authority, and judgment

Lack to spare budget (no financial profit)

Improvement in clinical markers (such as

reduced length of stay).

.