PROGRAM PENGENDALIAN RESISTENSI ANTIMIKROBA DI RUMAH

SAKITHARI PARATON. dr. SpOGK

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

AMR & RUMAH SAKIT?

• AMR banyak di Rumah sakit (ICU, ICCU, NICU, PICU, Int. Care, Rawatinap. Infeksi)

• Antibiotik sistemik banyakdigunakan di RS

• HAI prevalensi meningkat• Staff medis RS perlu pemahaman• 50-80% Antibiotik digunakan tidak

tepat.

4

Kategori

Hasil

Sby (%)

Semg(%)

Tidak ada indikasi terapi

76 53

Tidak ada indikasi

profilaksis55 81

4AMRIN STUDY : 2002-2005

PENGGUNAAN ANTIBIOTIK DI RUMAH

SAKIT

THE PROBLEM

• Blood stream• Pneumonia• UTI• SSI

ANTIBIOTIC USE

• more difficult to treat• more procedures• high cost• ICU use• failure morbidity and mortality

AMRHAI

PREVALENCE of ESBL in INDONESIA

ESBL PRODUCINGBACTERIA

9

2835

40

66

0

10

20

30

40

50

60

70

2000 2005 2010 2013 2016

pres

enta

ge

ESBL

AMRIN

AMRIN

RSDSRSDS

WHO/WHO/PPRA

26-56%

surveillance 201645-89%

Table. Antibiotic susceptibility (n) pattern of ESBL producing E.coli

7

RSDS RSSA RSDM RSDK RSSD RSP TOTALCefotaxime 0.17 0.00 NA 1.57 3.31 NA 0,78Ceftriaxone 0.00 0.00 2.62 5.93 NA 0.00 1,19Ceftazidime 0.17 0.00 12.07 4.19 8.33 0.00 3,83Cefepime 0.34 42.06 26.21 9.42 25.62 0.00 12,78Ciprofloxasin 16.10 29.37 10.00 18.32 7.50 10.42 15,21Amikacin 97.95 95.24 82.99 96.34 73.33 98.96 92,4Gentamycin 61.43 69.05 62.15 10.99 56.30 63.54 55,12Fosfomycin 92.86 100.00 NA 78.57 82.89 NA 90,85Piperacillin-tazobactam

49.57 76.19 NA 76.44 65.81 66.67 60,4

Cefoperazone-sulbactam

53.85 NA 83.33 72.73 57.98 15.63 57,08

Meropenem 99.83 98.41 98.96 95.29 94.96 100.00 98,51Levofloxacin 20.14 29.37 9.00 21.48 15.38 10.42 17,66Tigecyclin 78.08 99.21 97.92 99.48 40.63 100.00 94,67

Data surveillance PPRA RSDS-Balitbangkes-WHO 2013

GLOBAL AMR

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN

When I was asked to chair the Review on Antimicrobial Resistance (AMR), I was

told that AMR was one of the biggest health threats that mankind faces now

and in the coming decades. My initial response was to ask, ‘Why should an

economist lead this? Why not a health economist?’ The answer was that many of

the urgent problems are economic, so we need an economist, especially one versed

in macro-economic issues and the world economy, to create the solutions.

PENDAHULUAN

MASALAH GLOBAL

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN

THE AMR IMPACTS

MASALAH GLOBAL

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN

WHO 2013

700.000 / tahun

10.000.000/tahunUSD. 100 TRILLIUN

(Jim O Neill 2015)

2050

2013

WHO; Global Action Plan

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN

1. Improve awareness and understanding of antimicrobial resistance through effective communication, education and training

2. Strengthen the knowledge and evidence base through surveillance and research.

3. Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures.

4. Optimize the use of antimicrobial medicines in human and animal health.

5. Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions.

Problems

Map

AMRRS

R AB/ DR

R AB / self

medikasi

FoodResidu AB

(+)

OTC/Apatek

Growthpromotor

Pertanian/ Peternakan/perikanan

Cegahinfeksi

Insentif

Knowledge

Mikroklinik

ASP

Farmasiklinik

TOP TOP MGT

KM/KFT

Kurikulum

Training/SeminarWorksho

p

Regulasi

Knowledge

Regulasi

KlinisiPPI

PERLUNYA HIGH QALITY CARE

KASUSOPERASI SEMBUH

IDO SEMBUH

MENINGGAL

CACAT

• DELAYED • COST • TENAGA• KENYAMANAN• NEGATIVE

PROMOTION

HEALTH RESOURCES IN INDONESIA 2016

Profesion total

Specialist 32.280

GP 116.900

Dentist 31.360

Midwife 400.000

Nurse 288.000

Pharmacist 54.900.18

Facilities total

Hospital 2.415

Health center 9.600

Drug store 24.000

Medical Faculty 73

Dentistry Faculty 27

PharmaceuticalFaculty

127

Midwife Academy 720

Nurse academy 300

REGULASI SEBAGAI LANDASAN HUKUM

KPRA – RSPERMENKES no 8/2015

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN

pasal 6 Setiap rumah sakit harus melaksanakanProgram Pengendalian Resistensi Antimikrobasecara optimal.

pasal 7 susunan organisasi Komite / Tim PelaksanaProgram Pengendalian Resistensi Antimikroba

pasal 8 Keanggotaan tim pelaksana Program Pengendalian Resistensi Antimikroba rumahsakit

PARADIGMA MENGATASI BAKTERI RESISTEN

CegahTransmisi

AMR

CegahTransmisi

AMR

TemukanANTIBIOTIK

baru

TemukanANTIBIOTIK

baru

Host defence

/Immunitas

Host defence

/Immunitas

Menggunakan normal

flora

Menggunakan normal

flora

CegahResistensi

CegahResistensi

AntibiotikBijak

AntibiotikBijak

ASPASP

PPI/Universal precaution

PPI/Universal precaution

Cuci TanganCuci Tangan

Lama, Cost tinggi, SulitLama, Cost tinggi, Sulit

Save Normal

Flora

Save Normal

FloraASP,

LimitasiAntiseptik

ASP, Limitasi

Antiseptik

Pro-Pre biotik

Pro-Pre biotik

ANTIBIOTIK TERAPI DAN PROFILAKSIS DALAM RANGKA PENGENDALIAN

RESISTENSI ANTIBAKTERI DI RUMAH SAKIT

HARI PARATON. dr. SpOGK

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

• Anak 1,4 tahun, operasi Tetralogy Fallot hari 16. • Temp/ 37-39C, PCT > 5, lekosit 23.000. • Pus luka op. Pathogen: Acinotobacter baumannii• Resistance to Cephalosphorine, Meropenem, Amikacin,

Fosfomycin.

ANTIBAKTERITERAPI

ANTIBAKTERITERAPI

25

PRINSIP PENANGANAN PASIEN INFEKSI

infeksiinfeksi

Bakteri

Bakteri

Non-Bakter

i

Non-Bakter

i

antibiotikempiri

k

antibiotikempiri

k

mikrobiologi

mikrobiologi

antibiotik

definitif

antibiotik

definitif

si• stop

• Monitoring

• follow up• deeskala

si• stop

source

control

source

control

LANGKAH PERESEPAN ANTIBAKTERI

1. Apakah pasien sakit infeksi ?suhu tubuh > 38C, Nadi >90

2. Apakah infeksi bakteriLekosit>11.000, CRP(+), PCT (+)

3. Apakah ada penyebab / sumber

infeksi?kateter, drain, tampon, abces

• Demam Berdarah ?• Stroke ?• Asthma attack ?

DOSIS DAN WAKTU PEMBERIAN ANTIBIOTIKPEMICU MUTASI BAKTERI RESISTEN

MIC: Minimal inhibitotr concentration MPC: mutant prevention concentratration)

MPC

MIC

Window of Selection

ANTIBAKTERITERAPI

ANTIBAKTERIPROFILAKSIS

PROFILAKSIS

1. Antibakteri, yang digunakan untuk mencegahkomplikasi infeksi padatindakan operasi.

2. diberikan sebelum operasi, ulangan saat operasi atausetelah operasi

3. batasan waktu: tidakmelebihi 24 jam

INDIKASI PROFILAKSIS

• GOLONGAN OPERASI• bersih• bersih kontaminasi• kontaminasi• kotor

Antibiotika profilaksis

kolonisasi

Profilaksis Dosis Tunggal v/s Multipel

Single-dose versus multiple-dose antibiotic prophylaxis for the surgical treatment of closed fractures .

Slobogean.et.al. Acta Orthopaedica 2010; 81 (2): 256–262

Fakta laporan

Tidak ada perbedaa

n signifikan

Results: A total of 540 patients were recruited; (females73.7% of total ). The performed surgicalprocedures were 547. The rate of wound infection was 10.9%. Multivariable logistic analysisshowed that; ASA score > 3; (p= <0.001), wound class (p= 0.001), and laparoscopic surgicaltechnique; (p= 0.002) were significantly associated with prevalence of wound infection. Surgicalprophylaxis was unnecessarily given to 311 (97.5%) of 319 patients for whom it was notrecommended. Prophylaxis was recommended for 221 patients; of them 218 (98.6 %) were givenpreoperative dose in the operating rooms. Evaluation of prescriptions for those patients showedthat; spectrum of antibiotic was adequate for 160 (73.4%) patients, 143 (65.6%) were givenaccurate doses, only 4 (1.8%) had the first preoperative dose/s in proper time window, and for186 (85.3%) of them prophylaxis was extended post-operatively. Only 36 (6.7%) prescriptionswere found to be complying with the stated criteria.

Conclusion: The rate of wound infection was high and prophylacticantibiotics were irrationally used. Multiple interventions areneeded to correct the situation.

cara pemberian AB PROFILAKSIS

• Antibakteri– Cefazolin 2 g– Cefuroxime 1,5 g

• dikamar operasi• i.v/drip dalam 100 ml NS• 30 menit sebelum insisi• dalam 15 menit• tanpa skin test• tidak perlu pemberian AB oral

pasca operasi

SIGN 2015

ProsedureAntibiotik Evidence

Level Odd.Rt

Sectio Cesarea HR 1 0.41

Histerektomi TAH / TVH R 1 0.17

Tonsilectomy NR 1

Luka pada wajah NR 1

Partus normal + episiotomi NR 1

Strumecomy NR 1 -

Ca Mammae R 1

Appendectomy HR 1 0.58

Colorectal surgery HR 1

Hernia NR 1

TUR prostate HR 1

Arthroplasty HR 1

Pemasangan kateter NR 1

3 - TAKE HOME MESSAGE

1. RS melaksanakan Permenkes no.8/20152. RS memiliki kebijakan, pedoman dan PPK

penggunaan antibiotik terapi dan profilaksis3. penggunaan antibiotik bijak menekan jumlah dan jenis penggunaan antibiotik menekan angka komplikasi, resistensi, kesakitan

dan kematian menekan pembeayaan pelayanan pasien

4. Perlu adanya monev dan surveillance

PREVALENCE of ESBL in INDONESIA

HARAPAN BERSAMA

9

2835

40

60

40

30

20

0

10

20

30

40

50

60

70

2000 2005 2010 2013 2016 2017 2018 2019

pres

enta

ge

ESBL

AMRIN

AMRIN

RSDSRSDS

surveillance 201645-89% HARAPAN

KITA BERSAMA