PROGRAM PENGENDALIAN

RESISTENSI ANTIMIKROBA DI RUMAH

SAKIT
HARI PARATON. dr. SpOGK
KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA
 AMR & RUMAH SAKIT?

• AMR banyak di Rumah sakit (ICU,

ICCU, NICU, PICU, Int. Care, Rawat
inap. Infeksi)
• Antibiotik sistemik banyak
digunakan di RS
• HAI  prevalensi meningkat
• Staff medis RS perlu pemahaman
• 50-80% Antibiotik digunakan tidak
tepat.
 PENGGUNAAN
ANTIBIOTIK DI RUMAH
SAKIT

Hasil
Kategori Sby Semg
(%) (%)
Tidak ada
indikasi 76 53
terapi

Tidak ada
indikasi 55 81
profilaksis

AMRIN STUDY : 2002-2005

4 4
 THE PROBLEM
ANTIBIOTIC
USE

• Blood stream
• Pneumonia
HAI AMR •
•
UTI
SSI

• more difficult to treat

• more procedures
• high cost
• ICU use
• failure  morbidity and mortality
ESBL PRODUCING
BACTERIA

PREVALENCE of ESBL in INDONESIA

70
66
60 surveilla
nce 2016
50 45-89%
presentage

40 40 WHO/
35 PPRA
30 26- ESBL
28 56%
20 RSDS
RSDS
10 9 AMRI
0
N
2000 2005 2010 2013 2016
 Table. Antibiotic susceptibility (n) pattern of ESBL producing E.coli

RSDS RSSA RSDM RSDK RSSD RSP TOTAL

Cefotaxime 0.17 0.00 NA 1.57 3.31 NA 0,78
Ceftriaxone 0.00 0.00 2.62 5.93 NA 0.00 1,19
Ceftazidime 0.17 0.00 12.07 4.19 8.33 0.00 3,83
Cefepime 0.34 42.06 26.21 9.42 25.62 0.00 12,78
Ciprofloxasin 16.10 29.37 10.00 18.32 7.50 10.42 15,21
Amikacin 97.95 95.24 82.99 96.34 73.33 98.96 92,4
Gentamycin 61.43 69.05 62.15 10.99 56.30 63.54 55,12
Fosfomycin 92.86 100.00 NA 78.57 82.89 NA 90,85
Piperacillin-
49.57 76.19 NA 76.44 65.81 66.67 60,4
tazobactam
Cefoperazone-
53.85 NA 83.33 72.73 57.98 15.63 57,08
sulbactam
Meropenem 99.83 98.41 98.96 95.29 94.96 100.00 98,51
Levofloxacin 20.14 29.37 9.00 21.48 15.38 10.42 17,66
Tigecyclin 78.08 99.21 97.92 99.48 40.63 100.00 94,67

Data surveillance PPRA RSDS-Balitbangkes-WHO 2013

7
GLOBAL AMR

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN

PENDAHULUAN

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.
 MASALAH GLOBAL

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN

THE AMR IMPACTS
 MASALAH GLOBAL

2013 700.000 / tahun

WHO 2013
10.000.000/tahun
2050
USD. 100 TRILLIUN
(Jim O Neill 2015)

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN

WHO; Global Action Plan

1. Improve awareness and understanding of antimicrobial resistance

through effective communication, education and training
2. Strengthen the knowledge and evidence base through surveillance a
nd 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 ani
mal health.
5. Develop the economic case for sustainable investment that takes acco
unt of
the needs of all countries, and increase investment in new medicines,
diagnostic tools, vaccines and other interventions.

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN

Proble Pertanian/
Peternakan
ms /perikanan

Map Growth
promotor
Cegah
infeksi Regulasi

Food Kurikulu
Knowledg Residu AB Insenti m
e
(+) f

Training/
R AB / AMR R AB/ Knowled Seminar
OTC/Apate self
k DR ge Worksho
medikasi RS p

Regulasi
Mikro ASP KM/K
klinik FT

Farmasi TOP
klinik MGT
PPI Klinisi
 PERLUNYA HIGH QALITY CARE

KASUS
OPERASI SEMBUH

IDO SEMBUH

MENINGGAL
• DELAYED
• COST
• TENAGA
• KENYAMANAN CACAT
• NEGATIVE
PROMOTION
 HEALTH RESOURCES IN INDONESIA 2016

Profesion total Facilities total

Hospital 2.415
Specialist 32.280
Health center 9.600
GP 116.900 Drug store 24.000
Dentist 31.360 Medical Faculty 73
Dentistry Faculty 27
Midwife 400.000
Pharmaceutical 127
Nurse 288.000 Faculty
Midwife Academy 720
Pharmacist 54.900. Nurse academy 300 18
REGULASI SEBAGAI
LANDASAN HUKUM
 KPRA – RS
PERMENKES no 8/2015

pasal 6 Setiap rumah sakit harus melaksanakan

Program Pengendalian Resistensi Antimikroba
secara optimal.
pasal 7 susunan organisasi Komite / Tim Pelaksana
Program Pengendalian Resistensi Antimikroba
pasal 8 Keanggotaan tim pelaksana Program
Pengendalian Resistensi Antimikroba rumah
sakit

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN

PARADIGMA MENGATASI BAKTERI RESISTEN

Mengguna Host Temukan Cegah

Cegah
kan normal defence ANTIBIOTIK Transmisi
Resistensi
flora /Immunitas baru AMR

Save
Pro-Pre Lama, Cost PPI/Universal Antibiotik
Normal
biotik tinggi, Sulit precaution Bijak
Flora
ASP,
Limitasi Cuci Tangan ASP
Antiseptik
ANTIBIOTIK TERAPI DAN PROFILAKSIS
DALAM RANGKA PENGENDALIAN
RESISTENSI ANTIBAKTERI DI RUMAH SAKIT

HARI PARATON. dr. SpOGK

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.
ANTIBAKTERI
TERAPI
PRINSIP PENANGANAN
PASIEN INFEKSI

Bakter antibiot
ikempiri
i k antibiot
ik
mikrobiolo definitif
infeksi gi
sourc • Monitori
Non- e ng
Bakter contr • follow up
i ol • deeskala
si
• stop
25
 LANGKAH PERESEPAN
ANTIBAKTERI

1. Apakah pasien sakit infeksi ?

suhu tubuh > 38C, Nadi >90

2. Apakah infeksi bakteri

Lekosit>11.000, CRP(+), PCT
(+)
• Demam Berdarah ?
3. Apakah ada penyebab / • Stroke ?
sumber • Asthma attack ?
infeksi?
kateter, drain, tampon, abces
 DOSIS DAN WAKTU PEMBERIAN ANTIBIOTIK
PEMICU MUTASI BAKTERI  RESISTEN

MPC

Window of
Selection
MIC

MIC: Minimal inhibitotr concentration MPC: mutant prevention

concentratration)
ANTIBAKTERI
PROFILAKSIS
TERAPI
 PROFILAKSIS

1. Antibakteri, yang
digunakan untuk mencegah
komplikasi infeksi pada
tindakan operasi.
2. diberikan sebelum operasi,
ulangan saat operasi atau
setelah operasi
3. batasan waktu: tidak
melebihi 24 jam
 INDIKASI PROFILAKSIS

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

Antibiotika profilaksis
 Profilaksis Dosis Tunggal v/s Multipel

Fakta Tidak ada

laporan perbedaa
n
signifikan

Single-dose versus multiple-dose antibiotic prophylaxis for

the surgical treatment of closed fractures .
Slobogean.et.al. Acta Orthopaedica 2010; 81 (2): 256–262
Results: A total of 540 patients were recruited; (females73.7% of total ). The performed surgical
procedures were 547. The rate of wound infection was 10.9%. Multivariable logistic analysis
showed that; ASA score > 3; (p= <0.001), wound class (p= 0.001), and laparoscopic surgical
technique; (p= 0.002) were significantly associated with prevalence of wound infection. Surgical
prophylaxis was unnecessarily given to 311 (97.5%) of 319 patients for whom it was not
recommended. Prophylaxis was recommended for 221 patients; of them 218 (98.6 %) were given
preoperative dose in the operating rooms. Evaluation of prescriptions for those patients showed
that; spectrum of antibiotic was adequate for 160 (73.4%) patients, 143 (65.6%) were given
accurate doses, only 4 (1.8%) had the first preoperative dose/s in proper time window, and for
186 (85.3%) of them prophylaxis was extended post-operatively. Only 36 (6.7%) prescriptions
were found to be complying with the stated criteria.
Conclusion: The
rate of wound infection was high and prophylactic
antibiotics were irrationally used. Multiple interventions are
needed 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 Prosedure
Antibiotik
Evidence
Level
Odd.Rt

Sectio Cesarea HR 1 0.41

2015 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.8/2015
2. RS memiliki kebijakan, pedoman dan PPK
penggunaan antibiotik terapi dan profilaksis
3. 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
HARAPAN BERSAMA

PREVALENCE of ESBL in INDONESIA

70
surveillan
ce 2016
60 45-89% 60 HARAPAN
KITA
50 BERSAMA
presentage

40 40 40
35
30 30 ESBL
28
20 RSDS 20
RSDS
10 9 AMRI
0
N
2000 2005 2010 2013 2016 2017 2018 2019