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Interaksi dalam Penggunaan Antibiotika
Pejamu
Patogen Antibiotika
Farmakokinetik
Pasien Farmakodinamik
Epidemiologi
usia Tipe Infeksi
imunitas
riwayat antibiotika
Mikroorganisme
Resistensi lokal
Pertimbangan dalam Penggunaan
Antibiotika
Panduan mikrobiologi
Indikasi evidence based
Spektrum yang tersempit
Dosis yang tepat
Durasi seminimum mungkin
Usahakan monoterapi kecuali dalam kondisi
khusus
Klasifikasi Antibiotik
Bakterisidal Bacteriostatik
Beta-laktam Tetrasiklin
Penisilin Makrolid
Sefalosporin Lincosamid
Karbapenem Kloramfenikol
Monobaktam Nitrofurantoin
Glikopeptida Sulfametoksazol
Oksazolidinon Trimetoprim
Aminoglikosida
Fluorokuinolon
Inhibisi sintesis
Inhibisi sintesis
dinding sel
protein
FOM Penisilin
Makrolid Aminoglikosida penisilin-G
(Fosfomisin)
eritromisin kanamisin ampisilin
midecamisin, dibekacin kloksasilin,
amikasin Cefems
dll dll.
streptomicin sefalosporin
sefamisins
Kloramfenikol Tetrasiklin
Inhibisi sintesis
asam nukleat
Inhibisi
membran
Inhibisi sintesis DNA
sitoplasma
Kuinolon
Polipeptida Inhibisi sintesis RNA
polimiksin B, dll rifampisin
Foundation
Fig 20.2
Inhibition of Protein Synthesis by Antibiotics
Figure 20.4
Penicillins (PCN)
Natural Penicillins
Penicillin G, Penicillin V, Procaine, Bicillin
- Good gram +, fair gram - , good anaerobic
- PCN G = more effective IV or IM, but painful d/t
aqueous solution
- PCN V = PO; peak 2 - 4 hrs
Penicillins
Aminopenicillins (Broad Spectrum)
Amoxicillin (Amoxil), Ampicillin (Omnipen),
Bacampicillin HCL (Spectrobid)
- Gram + & Gram -
- Costlier
- Inactivated by beta-lactamases = ineffective against
Staphylococcus aureus (staph. A)
- Amoxicillin = most prescribed PCN derivative for
adults & children
Penicillins
Penicillinase - Resistant Penicillins
Methicillin (Staphcillin), Nafcillin (Unipen), Oxacillin
(Bactocil)
- Used to treat penicillinase-producing Staph A.
- Gram + , not effective against Gram -
- IV & PO
Penicillins
Extended - Spectrum Penicillins
Carbenicillin (PO), Mezlocillin, Piperacillin,
Ticarcillin, Ticarcillin-clavulanate (Timentin) - IM &
IV
- Broad spectrum - good gram (-), fair gram (+)
- Good against Pseudomonas aeruginosa
- Not penicillinase resistant
Semisynthetic Penicillins
Penicilinase-resistant penicillins
Carbapenems: very broad spectrum
Monobactam: Gram negative
Extended-spectrum penicillins
Penicillins + -lactamase inhibitors
Other Inhibitors of Cell Wall Synthesis
Cephalosporins
2nd, 3rd, and 4th
generations more
effective against gram-
negatives
Figure 20.9
Cephalosporins
Fungi of genus
Cephalosporium 4
Generations of
cephalosporins
Polypeptide antibiotics
Bacitracin
Topical application
Against gram-positives
Vancomycin
Glycopeptide
Important "last line" against antibiotic resistant S. aureus
Vancomycin
Considerations
- SE = Photosensitivity - sunburn rxn
- Should not be given to children < 8 yrs or to women in
last trimester of pregnancy - Irreversibly discolors
permanent teeth
- Tetracycline during 1st trimester of pregnancy can
cause birth defects
- Take on an empty stomach - antacids & dairy products
prevent absorption of the drug
Macrolides
Rifampycin
Inhibits RNA synthesis
Antituberculosis
Quinolones and fluoroquinolones
Ciprofloxacin
Inhibits DNA gyrase
Urinary tract infections
Fluoroquinolones (Quinolones)
Figure 5.7
Sulfonamides
Tulkens, P. M. ; OCS on Resistance and the Use and Misuse af Antimicrobial Therapy ; June 2000
Resistensi Antibiotik:
Profilaksis
Terapi empiris
Terapi definitif
Profilaksis Antimikrobial
Kemoprofilaksis efektif
Profilaksis pasca pajanan
(meningitis, viral influenza, infeksi Gonokokal,
sifilis, shigelosis, tuberkulosis, malaria)
Profilaksis operasi
Imunokompromais
Kemoprofilaksis inkonklusif
Post streptococcal glomerulonephritis
Infeksi Clostridium
Endokarditis infektif
PPOK
Fibrosis kistik
Pasca splenektomi
Kemoprofilaksis inefektif
Pencegahan pneumonia bakterial pada infeksi virus
Strategi untuk Terapi Empiris
Pasien
Eskalasi Deeskalasi
Cari superinfeksi
Pembentukan abses Tidak Perbaikan gejala klinis yang
Demam bukan akibat infeksi bermakna dalam 24-48 jam
Ya
ATAU
Monoterapi dengan antipneumococcal
fluorokuinolon
Am J Respir Crit Care Med. 2001;163:1730-1754.
Terapi Antimikrobial Empiris pada
Infeksi Abdominal
• Kolesistitis:
Florokuinolon, Piperasilin, Sefazolin+Ampi
• Kolangitis :
Karbapenem, Piperasilin, Sefoperazon
• Pankreatitis :
Karbapenem, Piperasilin, Ampi/sulbaktam
• Peritonitis :
Seftizoxime, Sefoxitin
Florokuinolon, Ampi/sulbaktam
Karbapenem, piperasilin/tazobaktam
+ Klindamisin/metronidazol
Cunha, 2005
TATALAKSANA PASIEN DENGAN IAI
(Intra-abdominal Infections)
IDSA SIS
Pasien risiko
IAI ringan-sedang IAI berat IAI
tinggi
Amp/sulbactam Pip/tazo Amp/sulbactam Pip/tazo
Ticar/clav Ticar/clav
Mono-terapi
Pip/tazo
Cefotetan
Cefoxitin
Ertapenem Imipenem Ertapenem Imipenem
Meropenem Imipenem Meropenem
Meropenem
Solomkin JS, et al. Clin Infect Dis. 2003;37:997-1005.
Mazuski JE, et al. Surg Infect. 2002;3:161-173.
TATALAKSANA PASIEN DENGAN IAI
IDSA SIS
Pasien risiko
IAI ringan-sedang IAI berat IAI
tinggi
Cefazolin atau 3rd/4th GC 3rd/4th GC atau 3rd/4th GC
cefuroxime or Cefuroxime atau +
Kombinasi
Metronidazol + +
Metronidazol Anti-anaerob
Kuinolon Ciprofloxacin AG AG atau cipro
+ + + +
Metronidazol metronidazol Anti-anaerob Anti-anaerob
*Bila menggunakan aztreonam, pertimbangkan penambahan proteksi
terhadap gram-positif dan juga terhadap bakteri anaerobe.
Solomkin JS, et al. Clin Infect Dis. 2003;37:997-1005.
Mazuski JE, et al. Surg Infect. 2002;3:161-173.
Terapi Antimikrobial Empiris dalam
Infeksi Traktus Genitourinarius
• Pielonefritis :
Florokuinolon
Sefalosporin generasi 3
Aminoglikosida
Karbapenem
Cunha, 2005
Infeksi Kaki Diabetik:
Terapi yang Disarankan
Infeksi Sedang
Amox/clav, amp/sulbactam
Cefoxitin, ceftriaxone, cefuroxime
Ticar/clav, piperacillin/tazobactam
Ertapenem, imipenem/cilastatin
TMP/SMX
Levofloxacin atau cipro + metronidazol
Vancomycin + ceftazidime (+metronidazol)
Linezolid, daptomycin