Name : Lie Khie Chen Birth : Jakarta Graduates

MD : FKUI 1994Internist : FKUI 2003Consultant : FKUI 2006PhD : FKUI 2014

Position: Medical Staff Department of Internal Medicine

Division of Tropical Medicine and Infectious Diseases Faculty of Medicine University of IndonesiaDr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

Member of National Committee Antimicrobial Control ResistanceProgram, Ministry of Health, Republic of Indonesia.

Chairman of Working Group of Antimicrobial Control Resistance ProgramDepartment of Internal MedicineDr. Cipto Mengunkusumo Hospital, Jakarta, Indonesia.

Curriculum Vitae

Prinsip Pemilihan AntibiotikEmpirik dan Definitif

Khie Chen

Division of Tropical Medicine and Infectious DiseasesDepartment of Internal Medicine

Medical Faculty University of Indonesia

Appropriate antimicrobial usage

Underusage Appropriate Overusage

Increase Increase mortality resistanceProlonged Costhospital stay

Underlying, comorbidityImmune statusSeverity/sepsisOrgan disfunctions

Underlying, comorbidityImmune statusSeverity/sepsisOrgan disfunctions

Gram positive/negativeCommunity/HCAI/HAISensitive/Resistance

Underlying, comorbidityImmune statusSeverity/sepsisOrgan disfunctions

Gram positive/negativeCommunity/HCAI/HAISensitive/Resistance

Antibiotic spectrumAvailabilityCost

In Vitro Spectrum Activity of Antibiotics

Quinolones

Carbapenems

Anaerobe

Glycopeptides

Tigecycline

3rd-generation cephalosporins

β-Lactam/ β-Lactamase Inhibitor

PseudoResistant Gram-positive

Resistant Gram-negative

Gram-positive

Gram-negative

Antibiotic

Varies by product within class

In Vitro Activity

No In Vitro Activity

Classification of antibiotic spectrum

n Gram positive/Gram negativen Aerobe/anaroben Anti-Pseudomonal/non-pseudomonaln Anti-MRSA/non MRSAn Limited spectrum/broad spectrum

Spectrum of Antimicrobial selecting for Empiric Treatment

CLASS SPECIFIC DRUGSANTI-STAPHYLOCOCCAL AGENTS AND MRSA

GlycopeptideOxazolidineLipopeptide

Vancomycin, TeicoplaninLinezolidDaptomycin

BROAD SPECTRUM DRUG WITH GRAM-POSITIVE AND GRAM-NEGATIVE ACTIVITY

Carbapenem

Quinolone

Beta lactam-Beta lactamase inhibitor

ImipenemMeropenemErtapenemLevofloxacinMoxifloxacinCiprofloxacinPiperacilin-TazobactamAmpicillin-SulbactamTicarcillin-Clavulanate

ANTI-PSEUDOMONAL CarbapenemAminoglycosideBeta lactam-Beta lactamase inhibitorQuinolone

Imipenem or MeropenemGentamicin, Tobramycin, AmikacinPiperacillin-TazobactamCiprofloxacin

ANTI-ANAEROBE NitroimidazoleCarbapenemQuinoloneBeta lactam-Beta lactamase inhibitor

MetronidazoleImipenem, MeropenemMoxifloxacinPiperacillin-Tazobactam

ANTI-CANDIDAL Echinocandin

Azole

CaspofunginMicafunginAnidulafunginFluconazoleVoriconazole

Strategi Terapi Antimikroba EmpirikPasien

Rawat jalan Rawat Inap

Kondisi stabil Infeksi berat/sepsis/risiko tinggi

Strategi Eskalasi Strategi Deeskalasi

Seleksi antibiotik sesuaiPola kepekaan dan resistensiStatus imun, komorbiditas dan disfungsi organ

Terapi antibiotik monoterapi/kombinasi

Pohan HT, 2005

Penggunaan Antibiotik Empirik

n Pilih antibiotik empirik berdasarkan kemungkinankuman penyebabn sesuai pola kepekaan dan resistensi di Rumah Sakit setempat.

n Pertimbangkan kondisi pasienn risiko terinfeksi kuman resisten, komorbiditas, risiko bila

terjadi kegagalan terapi, terdapatnya disfungsi dan kegagalanorgan yang mempengaruhi ekskresi obat

n Pilih antimikroba dengan spektrum paling sempitn kecuali pada infeksi berat atau sepsis.

Penggunaan Antibiotik Empirik

n Infeksi yang berasal dari komunitas dapat dimulaidengan antibiotik spektrum sempitn (Cephalosporin generasi ketiga, Penicillin, Fluroquinolon),

n Pasien dengan risiko tinggi terinfeksi patogen MDR, dapat dipertimbangkan pemberian antibiotik spektrumluasn Golongan Carbapenem, Betalaktamase inhibitor,

Antipseudomonal Cepahlosporin, baik monoterapi ataukombinasi.

Penggunaan Antibiotik Empirik

n Sebelum pemberian antibiotik, lakukan pemeriksaanmikrobiologi dengan sampel yang diambil secaralegeartis.

n Bilamana patogen definit dapat diidentifikasi, segeraganti antibiotik dengan spektrum yang lebih sempitn berdasarkan pilihan obat untuk patogen tersebut.

n Lakukan optimalisasi terapi antibiotik bila pasien dalamkondisi infeksi berat atau sepsis, risiko terinfeksipatogen resisten, atau pada hasil pemeriksaan kulturdidapatkan kuman MDR.

Penggunaan Antibiotik Empirik n Lakukan evaluasi respon terapi setiap 3 hari baik secara

klinis, laboratorik dan/atau pencitraan(radiologi/ultrasonografi). Bilamana dimungkinanlakukan pemantauan dengan biomarker (PCT kuantitatif).

Prinsip Penggunaan Antibiotik pada Sepsis

n Pemberian antibiotik spektrum luasn Pada sepsis berat dan renjatan septik diberikan

golongan spekturm luas monoterapi atau kombinasi termasuk golongan Carbapenem

n Sedangkan pada sepsis (awal) diutamakan golongan spektrum luas non Carbapenem

Prinsip Penggunaan Antibiotik pada Sepsis

n Antibiotik diberikan SEGERA : - Renjatan septik dosis pertama antibiotik diberikan dalam 1 jam.

n Lakukan pengambilan kultur darah sebelum antibiotik diberikan.n Lakukan pemantauan penggunakan antibiotik dengan

menggunakan biomarker (PCT) n Bilamana dimungkinkan.

- Lakukan eskalasi antimikroba bila terdapat progresipada sepsis berat.

- Lakukan deeskalasi setelah hasil kultur definit didapatkan.

Prinsip De-eskalasi Antibiotik

Deeskalasi dilakukan bila:- Patogen definit dapat diidentifikasi- Kondisi klinis/laboratorik pasien menunjukkan

perbaikan- Terdapat pilihan antibiotik dengan spektrum yang lebih

sempit- Terdapat pilihan antibiotik yang merupakan pilihan

untuk patogen tertentu

Eskalasi antibiotik

Apabila spektrum antibiotik sebelumnya dinilai belumadekuat, dapat dilakukan eskalasi antibiotik dengan cara:

- Meningkatkan spektrum terapi, - Melakukan kombinasi yang rasional- Optimalisasi dosis dan cara pemberian PKPD

Kasus 1

n Laki laiki 78 tahun, riwayat DM tidak terkontrol, terbentur 2 hariyang lalu, bengkak

n Semakin meluas dalam 2 hari. Mendapat Cefadroxil 1 hariyang lalu tidak respons

n Lab. Leukosit 15.000 Trombosit125.000 Gula darah 330 mg/dL Creatinin 2.4 mg/dL

Pertanyaan: Apa kemungkinan pathogen penyebab ?Apa antibiotik empirik yang akan diberikan ?

Uncomplicated SSTIs Complicated SSTIs (cSSTI) ABSSSIs

Superficial infections Involve deep soft tissues Significant comorbidity that complicates response to treatment (ie, diabetes, chronic kidney disease)

A severe subset of SSTI, but generally less severe than cSSTIs

Require antibiotics +/-surgical drainageeg, cellulitis, simple abscesses, impetigo, and furuncles

Require significant surgical interventioneg, infected ulcers or burns, major abscesses, extensive cellulitis, or infections of any severity in presence of specific medical comorbidities

Typically treated with parenteral antibioticseg, extensive cellulitis/erysipelas, wound and surgical site infections, and major cutaneous abscesses with surface area (erythema, edema or induration) ≥75 cm2

Defining SSTIs: FDA definitions

ABSSSI, acute bacterial skin and skin structure infection; SSTI, skin and soft tissue infection

Barie PS, Wilson SE. J Am Coll Surg 2015;220:105-116.e6; US Food and Drug Administration. Guidance for Industry Acute Bacterial Skin and Skin Structure Infections: Developing Drugs for Treatment. October 2013. Available at:

www.fda.gov/downloads/Drugs/.../Guidances/ucm071185.pdf; Pollack CV Jr, et al. J Emerg Med 2015;48:508-519.

22

8

8

19

3

4

9

2

13

5

9

- 5 10 15 20 25

S.aureus

S.epidermidis

Streptococcus spp

Proteus spp

Acinetobacter anitratus

Enterobacter aerogenes

Klebsiella pneumoniae

Pantoea agglomerans

Pseudomonas aeruginosa

E.coli

Kultur steril

jeni

s ku

man

jumlah kuman

Pola Kuman pada Infeksi Jaringan Lunak Komplikatadi Jakarta tahun 2009

Irwanto R, 2009

Risk factor Associated etiological pathogen

Diabetes mellitus S. aureus, group B streptococci, anaerobes, Gram-negative bacilli

Cirrhosis Campylobacter fetus, K. pneumoniae, E. coli, Capnocytophaga canimorsus, other Gram-negative bacilli, Vibrio vulnificus

Neutropenia P. aeruginosa

Cat/dog/rat bite wounds Pasteurella multocida / C. canimorsus, P. multocida /Streptobacillus moniliformis

Animal contact Campylobacter spp

Reptile contact Salmonella spp

Freshwater exposure Aeromonas hydrophila

Seawater (fish tank) exposure V. vulnificus, Mycobacterium marinum

IV drug abuse MRSA, P. aeruginosa

Subcutaneous drug abuse Anaerobes, especially E. corrodens

Risk factors for SSTIs and associated bacterial causes

SSTI, skin and soft tissue infections; MRSA, methicillin-resistant Staphylococcus aureus

Ki V, Rotstein C. Can J Infect Dis Med Microbiol 2008;19:173-184.

Irwanto R. 2009

3.3%

16.7%

70.0%

10.0%

0.0%0.0%0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

Resistensi & Sensitifitas

Stafilokokus spp terhadap

Oxasilin dan Cefoxitin

Se

Sa

Se 16.7% 10.0% 0.0%

Sa 3.3% 70.0% 0.0%

R S I

6.7%3.3%

66.7%

23.3%

0.0%0.0%0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Resistensi & Sensitifitas Stafilokokus spp terhadap Vankomisin

SeSa

Se 3.3% 23.3% 0.0%

Sa 6.7% 66.7% 0.0%

R S I

Pola Resistensi S. aureus dan S. epidermisis terhadap Oxacillin dan Vancomycin pada PasienInfeksi Jaringan Lunak Komplikata di Jakarta tahun 2009

Healthcare-associated (HA)-MRSA vs. community-associated (CA)-MRSA

Nathwani D, et al. J Antimicrobial Chemother 2008; 61:976–94

Parameter HA-MRSA CA-MRSA

Typical patient

Infection site

Transmission

Clinical settingof diagnosis

Medical history

Virulence ofinfecting strainAntibioticsusceptibility

Elderly, debilitated and/or critically or chronically ill

Often bacteraemia with no obvious infection focus.Also surgical wounds, open ulcers, IV lines andcatheter urines. May cause ventilator-associatedpneumonia

Within healthcare settings; little spread amonghousehold contacts

In an inpatient setting, but increasingly HA-MRSAInfections in soft tissue and urine are occurring inprimary care

History of MRSA colonisation, infection, recentsurgery; admission to a hospital or nursing home,antibiotic use; dialysis, permanent indwellingcatheterCommunity spread is limited, PVL genes usuallyabsentOften multi-resistant with result that choice of agentsoften very limited

Young, healthy people; students,professional athletes and military service personnel

Predilection for skin and soft tissue, producing cellulitis and abscesses. May cause necrotisingcommunity-acquired pneumonia, septic shockor bone and joint infections

Community-acquired. May spread in familiesand sports teams

In an outpatient or community setting

No significant medical history orhealthcare contact

Community spread occurs easily. PVL genesoften present, predisposing to necrotising softtissue or lung infection generally susceptibleto more antibiotics than HA-MRSA

Kasus 1n Kajian : infeksi kulit dan jaringan lunak kompikatan Faktor risiko : usia, diabetes melitus tidak terkontroln Pasien dengan kondisi berat dan sepsis serta AKI : strategi de-

eskalasin Infeksi berasal dari komunitas : luka benturan terinfeksin Kemungkian patogen :n Gram positif : Staph aureus/epidermidis, masih mungkin

infeksi MRSA, klinis progresifGram negatif : E.coli, K. pneumonia

Pseudomonas? (jarang ditemukan di komunitas)

Infection Likely pathogens TreatmentSuperficial infections suggestive of cellulitis, or new ulcer and antibiotic naive

Staphylococcal and streptococcal species

Relatively narrow-spectrum therapy usually sufficient

Chronic ulcer infection with history of multiple antibiotic courses

§ Polymicrobial§ Also consider

Enterobacteriaceae spp (esp. resistant strains), CNS, P. aeruginosa and MRSA

§ Combination therapy: antipseudomonal β-lactam agent (eg, piperacillin, pip-tazo, ceftazidime or a carbapenem), plus a fluoroquinolone (eg, ciprofloxacin)

§ Vancomycin for MRSA

Evidence of necrosis Usually polymicrobial, with both aerobes and anaerobes

IV therapy initially, switch to oral with clinical improvementCareful monitoring and frequent therapeutic titration

Diabetic foot infection: Pathogens and antibiotic choices

Ki V, Rotstein C. Can J Infect Dis Med Microbiol 2008;19:173-184; Eron LJ, et al. J Antimicrob Chemother 2003;52 Suppl 1:i3-17

Empirical antibiotic treatment of diabetic foot infections

Severity of infection

Expected pathogens Potential antibiotic agents Administration route Duration of treatment

Mild Staphylococcus aureus*Streptococci

Cephalosporins, clindamycin, co-amoxiclav

Oral 1-2 weeks

Moderate Similar to those for mild infections, plus Enterobacteriaceae

Co-amoxiclav, combination of quinolone + clindamycin

Oral or parenteral (to start)

2-3 weeks

Severe All pathogens, maybe anaerobes and Pseudomonasaeruginosa

Piperacillin-tazobactam, cefepime, carbapenem

Parenteral, with oral switch when stable

2-3 weeks

Recent Rx with antibiotics

Consider covering Ps. aeruginosa, MRSA

Piperacillin-tazobactam, cefepime, carbapenem

Parenteral 2-3 weeks

BacteremicƗ Most often S. aureus but others possible

Based on culture and sensitivity results

Parenteral 2-3 weeks

Osteomyelitisⱡ S. aureus, streptococci, Enterobacteriacae

Based on bone culture, if possible

Oral (perhaps after initial parenteral)

4-6 weeks (if not surgically resected)

No evidence supports superiority of parenteral route over oral administration except for patients who are bacteremic or for whom antimicrobials only appropriate antibiotics are in parenteral form; exclusion of abscesses, either clinically or radiologically (ulltrasound)* Skin colonization due to healthcare-associated methicillin-resistant S. aureus (MRSA) does not always require anti-MRSA coverageƗ Perform blood cultures if signs or symptoms of sepsis (systemic inflammatory response syndrome)ⱡ Avoid empirically selected therapy, if possible; ideal antibiotic-freetime before bone sampling for culture is probably 10-14 days

Uçkay I, et al. Diabetes Obes Metab 2014;16:305-316.

PPAB RSCM 2017

PPAB RSCM 2017

Antibiotik apa yang akan dipilih untukterapi empirik?

n Ampisilin Sulbactamn Amoxicillin- Asam Clavulanatn Clindamycinn Moksifloxacinn Ertapenemn Meropenemn Piperasilin tazobactamn Vancomycinn Linezolid

Factor type

Factors that adversely affect outcomes of surgical site/post-op infection

Factors that increase risk of treatment failure or mortality

Patient Age >40 years1

Obesity2

Comorbidities1,3,4

Immune function1

Alcoholism, smoking1

Poor performance/physical status1,4

Poor nutritional status5,6

Advanced age5,6

Comorbidities5,6

Smoking6

Higher APACHE II scores5,6

Low albumin level5,6

Significant CV disease6

Pathogen Antimicrobial resistance7 Resistant pathogen8

Treatment Inadequate initial antibiotic coverage5

Delayed intervention5Inadequate source control5

Inadequate initial antibiotic coverage5

Surgical Emergency procedure1,4

Complexity of procedure1,9

Prolonged operative time1,10

Wound classification1,10

Factors associated with treatment outcomes

1. Neumayer L, et al. J Am Coll Surg 2007;204:1178-1187. 2. Waisbren E, et al. J Am Coll Surg 2010;210:381-389. 3. Ata A, et al. Am Surg 2010;76:697-702. 4. Kaya E, et al. Surg Infect (Larchmt) 2006;7:519-526.

5. Solomkin JS, et al. Clin Infect Dis 2010;50:133–164. 6. Chow AW, et al. Can J Infect Dis Med Microbiol 2010;21:11-37. 7. Engemann JJ, et al. Clin Infect Dis 2003;36:592-598. 8. Dohmen PM. J Hosp Infect 2008;70 Suppl 2:15-20.

9. Varela JE, et al. Surg Endosc 2010;24:270-276. 10. Haridas M, Malangoni MA. Surgery 2008;144:496-501.

Kasus 2n Wanita 75 tahun riwayat Ca serviks

post histerekstomi+radiasi dan diabetes melitus, dirawat karenademam disertai menggigil sejak 1 hari yang lalu

n Hemodinamik stabil, suhu 39oC, FN 28x/menit

n Hb 12,8 Leuko 18.000 Trombosit305.000

n Ur 51 Cr 1.0n CRP 110 PCT 45.4n Urine lengkap Leuko penuh

Kasus 2n Infeksi saluran kemih komplikatan Faktor risiko, diabetes melitusn Riwayat radiasi, menimbulkan obstruksi saluran kemihn Infeksi sistemik/sepsisn Kemungkinan penyebab :

Gram negatif : E coli, K. pneumoniaGram positif : Stap epidemidis, Entrococcus fecalis

PPAB RSCM 2017

Antibiotik apa yang akan dipilih ?

§ Cotrimoxazole§ Fosfomycin§ Ampisilin Sulbactam§ Amoxicillin Asam Clavulanat§ Ceftriaxone§ Ciprofloxaxin§ Levofloxacin§ Ertapenem§ Meropenem

Kasus 3n Pria usia 81 tahun datang ke unit gawat darurat dengan keluhan

utama tidak sadar sejak 6 jam yang lalun Pasien dengan riwayat diabetes mellitus mendapat terapi

diamicron MR 1x30mg dan metformin 3x500mg, kontrol tidakteratur. Sejak 1 hari terakhir pasien demam tidak tinggi, nafsumakan menurun. Pasien pernah dirawat dengan CVD iskemik 3 bulan yang lalu, dan sempat mengalami komplikasi pneumonia saat perawatan. Pulang perawatan, pasien lebih banyak berada di tempat tidur, nutrisi melalui NGT.

n Riwayat penyakit dahulu : hipertensi, DM, penyakit jantungkoroner.

Kasus 3n Pemeriksaan fisik :n Tampak sakit berat, GCS : 10, TD 90/40, nadi 135 kali/menit,

suhu 36.5oC, pernafasan 30x/menit. n Pasien nampak anemis, pupil isokor.n Paru terdengar ronki basah kasar di kedua lapang paru.

Pemeriksaan jantung dan abdomen dalam batas normal.n Lab : Hb 10.8g/dl Lekosit 11.900/ul

Ht : 32 Trombosit 125.000/ulSGOT 13 U/L SGPT 40 U/LAlbumin 2.1 mg.dl Ureum 107 Cr : 1.3 Gula darah sewaktu 335Na 143 meq/L K 4.8 meq/LAGD pH 7.182/ pCO2 39.6/ pO2 57 / HCO3 13.9 /BE -13.0

Kasus 3n Masalah : Pneumonia

hospital associated infections§ Faktor risiko : usia lanjut, diabetes melitus, post

CVD dengan imobilisasi, instrumentasin Sepsis dengan hemodinamik tidak stabil

disfungsi organ multiple : DIC, AKI, asidosis metabolikn Infeksi masih mungkin berasal dari RS, kemungkinan

pathogen resisten (MDR)

Patient Characteristic that increased risk infected with MDR

n Prolonged hospitalizationn HCU/ICU admissionn Chronic diseasesn Immune compromisedn Post surgical or medical proceduren Instrumentationn History of MDRO infections

Antimicrob Agents Chemother. 2006 Jan;50(1):43-8https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0193431

Antimicrobial Resistance & Infection Control20187:79

2016 ATS/IDSA guidelines: Initial empiric antibiotic therapy for HAP (non-VAP) not at high risk of mortality

Kalil AC, et al. Clin Infect Dis 2016 Jul 14. [E-pub ahead of print]

With no factors for MRSA With factors for MRSA

One of the following:§ Piperacillin-tazobactam 4.5 g

IV q6hOR§ Cefepime 2 g IV q8hOR§ Levofloxacin 750 mg IV dailyOR§ Imipenem 500 mg IV q6h§ Meropenem 1 g IV q8h

One of the following:§ Piperacillin-tazobactam 4.5 g IV q6hOR§ Cefepime or ceftazidime 2 g IV q8hOR§ Levofloxacin 750 mg IV daily§ Ciprofloxacin 400 mg IV q8hOR§ Imipenem 500 mg IV q6h§ Meropenem 1 g IV q8hOR§ Aztreonam 2 g IV q8h

PLUS§ Vancomycin 15 mg/kg IV q8-12h with goal to target

15-20 mg/mL trough levelOR§ Linezolid 600 mg IV q12h

2016 ATS/IDSA guidelines: Initial empiric antibiotic therapy for HAP at high risk of mortality or receipt of IV antibiotics during the prior 90 days

Kalil AC, et al. Clin Infect Dis 2016 Jul 14. [E-pub ahead of print]

Two of the following, avoid 2 β-lactams:

§ Piperacillin-tazobactam 4.5 g IV q6hOR§ Cefepime or ceftazidime 2 g IV q8hOR§ Levofloxacin 750 mg IV daily§ Ciprofloxacin 400 mg IV q8hOR§ Imipenem 500 mg IV q6h§ Meropenem 1 g IV q8hOR§ Amikacin 15-20 mg/kg IV daily§ Gentamicin 5-7 mg/kg IV daily§ Tobramycin 5-7 mg/kg IV dailyOR§ Aztreoname 2 g IV q8h

PLUS§ Vancomycin 15 mg/kg IV q8-12h with

goal to target 15-20 mg/mL trough levelOR§ Linezolid 600 mg IV q12h§ Coverage for MSSA if MRSA coverage is

not used

Antibiotik apa yang akandiberikan?

n Ampisilin sulbactam+Levofloxacinn Meropenem+Levofloxacinn Meropenem+Amikacinn Piperacillin tazobactam+Levofloxcin+Vancon Piperacillin tazobactam+Amkacin+Linezolidn Tygeciline+Meropenemn Polymoxin+Meropenem

Kasus 3n Pasien dirawat di ICU, setelah dilakukan resusitasi

hemodinamik stabiln Didapatkan hasil kultur darah steril, kultur sputum ETT

Pseudomonas aeruginosa resisten dan Candida tropicalis. Hasil uji kepekaaan: Pseudomonas resistenterhadap semua antibiotik kecuali fosfomisin dan kotrimoksasol.

Kasus 3

n Hasil kultur : MDR Pseudomonas aeruginosan Kolonisasi candida tropicalis, possible pathogen

systemic candidiasis

Pemilihan Antimikroba Definitif

Hasil pemeriksaan kultur mikrobiologi

Kolonisasi Patogen

Tidak diterapi Sensitive Resisten/MDR

Optimalisasi KombinasiAntibiotik yg PKPD Antibiotik

direkomendasikan

Antimicrobial selection for definite treatment

n MRSAVancomycinTeicoplaninLinezolide

QuinopristinDalfopristinTygeciclineDaptomycinCeftobiprole

n PseudomonasCeftazidimeMeropenem, Imipenem,DoripenemCefepimeAztreonamPip-TazobactamAmikacinCiprofloxacin Levofloxacin

n AcinetobacterAmpicillin SulbactamPip-TazobactamImipenem, Meropenem, DoripenemTygecycline

Source: Cheston B Cunha, Burke A Cunh Antibiotic Essentials 2017American Thoracic Society,Am J Respir Crit Care Med. 2005;171:388–416

Eccmid 2011

Polymixin/Colistin

n Polymixin E (Colistin), Polymixin En Sediaan : Colimethate : pro drug dari Colistin, Polimyxin

Sediaan oral tidak dapat digunakan untuk infeksi sistemikkarena tidak diabsrobsi dalam saluran cerna.

n Indikasi : terapi definitif MDR/PDR Pseudomonas aeruginosa danAcinetobacter baumanii

Dalam kombinasi dengan Carbapenem Grup2, PIPTAZOFosfomycin, Aminoglicosida

n

Kesimpulann Pemilihan terapi antimikroba empirik adalah

ketrampilan mengkaji data klinis, faktor risiko, beratdan progresivitas penyakit; menganalisis kemungkinanpathogen dalam memberikan pengobatan yang optimal

n Evaluasi terhadap respon terapi secara klinis, laboratorisdan radiologis penting dilakukan dalam mengevaluasiterapi empirik; untuk melakukan eskalasi maupundeeskalasi terapi.

Faculty of Medicine University of IndonesiaJakarta, Indonesia

Dr. Cipto Mangunkusumo General HospitalJakarta, Indonesia.

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