TINJAUAN

FARMAKOLOGI
PEMILIHAN ANTIBIOTIK

Noor Wijayahadi
2011
 Kategori EBM
Meta analisis & Syst Review 1A
Randomized Controlled Trial 1B
Non Randomized Trial 2A
Quasi Experimental 2B
Observational Study 3
Expert Opinion, Clinical Experience 4
Uji Praklinik
Uji In-Vitro
FAKTOR BERPENGARUH PADA
TERAPI ANTIBIOTIKA

OBAT

PASIEN KUMAN
 JENIS KUMAN
Gram Positive Cocci
Gram Positive Bacilli
Gram Negative Cocci
Gram Negative Bacilli
Anaerobes
Spirochetes
Mycobacteria
 kuman berdasar lokasi infeksi
Mouth Skin/Soft Tissue Bone and Joint
Peptococcus S. aureus S. aureus
Peptostreptococcus S. pyogenes S. epidermidis
Actinomyces S. epidermidis Streptococci
Pasteurella N. gonorrhoeae
Gram-negative rods

Abdomen Urinary Tract Upper Respiratory

E. coli, Proteus E. coli, Proteus S. pneumoniae
Klebsiella Klebsiella H. influenzae
Enterococcus Enterococcus M. catarrhalis
Bacteroides sp. Staph saprophyticus S. pyogenes

Lower Respiratory Lower Respiratory Meningitis

Community Hospital S. pneumoniae
S. pneumoniae K. pneumoniae N. meningitidis
H. influenzae P. aeruginosa H. influenza
K. pneumoniae Enterobacter sp. Group B Strep
Legionella pneumophila Serratia sp. E. coli
Mycoplasma, Chlamydia S. aureus Listeria
 Prinsip Dasar Antibiotik
Toksisitas Selektif
Mekanisme kerja
Broad or Narrow spectrum
Bactericidal atau bacteriostatic
Time or Concentration Dependent
Oral atau Parental
Half-Lives
Kombinasi antibiotik
 Selective toxicity

Antibiotik harus sudah

menghambat/membunuh
microorganism pada kadar rendah,
tetapi belum menimbulkan efek
toksik

No antibiotic is completely safe

ANTIBIOTIK
 Mekanisme Kerja Antimikroba
Hambat sintesa dinding sel Ganggu DNA/RNA
kuman Rifamycins
Penicillins
Cephalosporins
Quinolones
Carbapenems
Monobactams (aztreonam) Hambat metabolisme folat
Vancomycin
Trimethoprim
Hambat sintesa protein
Chloramphenicol Sulfonamides
Tetracyclines
Glycylcycline (Tigecycline) Lain-lain
Macrolides
Metronidazole
Clindamycin
Streptogramins Daptomycin
(quinupristin/dalfopristin)
Oxazolidinones (linezolid)
Aminoglycosides
Classification of Antimicrobials
 Penisilin
Narrow-spectrum
Penicillin G (IV)
Penicillin VK (PO)
Penicillinase-resistant Antistaphylococcal
Cloxacillin, dicloxacillin (PO)
Nafcillin (IV)
Oxacillin (IV)
Extended-spectrum
Ampicillin/.Amoxicillin (PO)
Amoxicillin + clavulanate (PO)
Piperacillin (IV)
Ticarcillin (IV)
 Cephalosporins

1st Gram (+)

2nd spektrum lebih luas Gr (-)
3rd spektrum Gr (-) Gr (+)
Serious Gram negative infections
CeftriAXone and cefotAXime meningitis
Ceftazidime anti-Pseudomonal
4th cefepime Anti-Pseudomonal coverage
Spektrum Gr (-)/Gr (+) baik
 Cephalosporins
1st Gen 2nd Gen 3rd Gen 4th Gen

Cefadroxil * Cefaclor * Cefdinir Cefepime

Cefazolin Cefamandole Cefoperaxone
Cefelixin * Cefonicid Cefotaxime
Cephalothin Ceforanide Ceftazidime
Cephaprin Cefotetan Ceftibuten
Cephradine * Cefoxitin Ceftizoxime
Cefuroxime
Ceftriaxone
moxalactam

* Oral Agent
First generation cephalosporins:
cephalothin, cefazolin, cefalexin. These drugs
have good activity against most Gram positive cocci
(Streptococcus, pneumococcus but not or
methicillin-resistant Staphylococcus). They are more
active against Gram negative organisms
(Escherichia co1i Kiebsiella pneumoniae, and the
indole negative Proteus mirabilis) than are the
natural penicillins. They are effective against some
anaerobic cocci (Peptococcus and
Peptosteptococcus, but NOT Bacteroides fragilis).
They are ineffective against Pseudomonas
aeruginosa, Enterobacter, and indole-positive
Proteus species.
These drugs do not cross the blood-brain barrier.
 Second generation
cephalosporins:
cefuroxime, cefamandole, cefoxitin,
cefaclor. The spectrum is extended to more
Gram negative bacteria Enterobacter species,
Klebsiella species, and indole-positive Proteus
species. Also, Haemophilus influenza is
covered by cefuroxime, cefamandole, cefaclor;
Bacteroides fragilis by cefoxitin.
These drugs do not achieve adequate levels in
the CSF.
 Third generation
cephalosporins:
moxalactam, cefaperazone, ceftazidirne,
ceftriaxone. These drugs demonstrate extended
Gram negative coverage, are more resistant to non -
Staphylococcus b-lactamase, and readily cross the
blood-brain barrier. The spectrum is extended to
include: Enterobacter, Pseudomonas (ceftazidime
and cefaperazone only), Serratia, b-lactamase
producing Haemophillus influenza and Neisseria
species.
Only cetizoxime and moxalactam retain good activity
against Bacteroides fragilis.
 Fourth generation
forth generation of cephalosporins (e.g.
cefepime) are available, these are
comparable to third-generation but more
resistant to some betalactamases.
 Pharmacokinetics

Some cephalosporins may be given orally

but most are given parenterally (IM or IV).
They are widely distributed in the body like
penicillins.
Some such as cefoperazone, cefotaxime,
cefuroxime, ceftriaxone, and ceftazidime
(third generation) also cross the blood-brain
barrier and are drugs of choice for
meningitis due to Gram-negative intestinal
bacteria.
Almost all are primally eliminated via the
kidneys and are actively secreted by the
renal tubules. Cefaperazone and
ceftriaxone are eliminated through the
biliary tract.
 Adverse effects
Hypersensitivity reactions very similar to those that occur with
penicillins may be seen.
Nephrotoxicity and intolerance to alcohol (disulfiram like
reaction) has been reported. (cefamandole, cefotetan,
moxalactam, cefoperazone )
Diarrhea may occur with oral forms. Many second and
particularly third generation cephalosporins are ineffective
against Gram-positive organisms, especially methicillin
resistant Staphylococci and Enterococci.
During treatment with such drugs, these resistant organisms
as well as fungi, often proliferate and may induce
superinfection.
Hyperprothrombinemia, Thrombocytopenia, Platelet
dysfunction. Administration of vitamin K (10mg) twice a week
can prevent this.
 Uses:
A cephalosporin with or without an
aminoglycoside is first-line treatment of
Klebsiella.
First generation cephalosporins are used for
surgical prophylaxis of wound infection.
Third generation cephalosporins are used to
treat meningitis due to pneumococci,
meningococci, and Haemophillus influenza.
Ceftriaxone is the drug of choice for treating
beta-lactamase producing Neisseria gonorrhea.
 Drug interaction
Cephalosporins demonstrate synergistic
activity when combined with an
aminoglycoside to treat Klebsiella.
Carbapenems and monobactams
Carbepenems are a new class of drugs which are
structurallv similar to the penicillins. These drugs
were developed to deal with betalactamase
producing Gram-negative organisms, which were
resistant to broad spectrum and extended spectrum
penicillins.
Carbapenems are derived from Streptomyces
species and one example is the semisynthetic
imipenem which acts in the same way as the other
beta-lactams.
The most extensively studied drug is imipenem.
 Carbapenems
Imipenem(w/cilastin), Meropenem
Broad Coverage (EVERYTHING)
Points:
Cilastin prevents renal excretion of
imipenem to increase life
Imipenem associated with Seizure
Monobactam
Aztreonam
Only GRAM NEG coverage (Including
Pseudomonas)
NO CROSS REACTIVITY WITH PENICILLIN
 Imipenem:
Mechanism of action: Imipenem, like other b-
lactams, binds to penicillin binding proteins. Hence it
disrupts cell wall synethesis and is bactericidal.
Antimicrobial spectrum: Imipenem differs from the
penicillins in its antimicrobial spectrum. It is a broad-
spectrum antibiotic with excellent activity against a
variety of gram positive and gram negative organism
(both aerobic and anaerobic). It is resistant to most
forms of b-lactamase, including that produced by
staphylococcus. However, methicillin-resistant
staphylococcus is usually resistant to imipenem.
Susceptible organisms include: Streptococci,
Enterococci. Staphylococci, Lister,
Enterobacteriaceae, Pseudomonas, Bacteroides,
and Clostridium.
Metabolism: Imipenem is rapidly hydrolyzed by the
enzyme, dihydropeptidase, which is found in the
brush border of the proximal renal tubule. It is
always administered with cilastatin, an inhibitor of
dipeptidase.
Side efects: Individuals who are allergic to the
penicillins may demonstrate cross-reactivity with
imipenem.
Imipemem may produce nausea and vomiting.
Seizures have been reported with high doses, particularly
in patients with renal failure.
Meropenem
It is similar to imipenem.
It is not degraded by dehydropeptidase, thus
no cilastatin is needed.
Excessive levels in kidney failure can cause
seizures with imipenem but not with
meropenem.
 Monobactam
Aztreonam: This drug is a monocyclic beta-lactam (a
monobactam).
Mechanism of action: Aztreonam interacts with penicillin
binding proteins and induces the formation of long
filamentous bacteria.
Antimicrobial spectrum: The antimicrobial spectrum of
aztreonam differs from that of other beta-lactams. It more
closely resembles the spectrum of the aminoglycosides.
Gram positive and anaerobic bacteria are resistant.
Susceptible organisms include: (It has an unusual spectrum being
active only against Gram-negative aerobic rods) Enterobacteriaceae,
Pseudomonas, Hemophillus and Neisseria. Aztreonam is
resistant to the beta-lactamase produced by gram negative
organisms.
Side effects: Generally, the drug is well tolerated. Patients
who are allergic to penicillins do not exhibit cross-reactions
with aztreonam.
 beta-Lactamase Inhibitors
Clavulanic Acid, Sulbactam and tazobactam
Mechanism of action: These drugs have poor
antimicrobial activity. They are inhibitors of
bacterial beta-lactamase.
They are potent inhibitors of many bacterial beta-
lactamases and can protect hydrolyzable
penicillins from inactivation by these enzymes.
They are included in combination with
amoxacillin (Augmentum) or with ticaricillin. In
particular, clavulanic acid is an irreversible,
"suicide" inhibitor of beta-lactamase.
They are available only in fixed
combinations with specific penicillins:
Ampicillin + sulbactam
Amoxicillin + clavulanic acid
Ticarcillin + clavulanate potassium
Piperacillin + tazobactam sodium
Polypeptide antibiotics
Bacitracin
Topical application Against gram-positives
Vancomycin
Glycopeptide
Treat Methicillin-resistant S. aureus
Bacteriostatic Not bactericidal
Never develop resistance while on treatment.
RED MAN syndrome slow infusion
Can be nephro and oto-toxic
Antimycobacterium antibiotics
Isoniazid (INH)
Inhibits mycolic acid synthesis
Neuropathy Treat with B complex vitamins
(particularly B-6)
Seizure in overdose
Ethambutol
Inhibits incorporation of mycolic acid
Color blindness Snell Chart
Protein Synthesis Inhibitors
Rifamycins
Quinolones
Inhibitors of Folate Metabolism
Metronidazole
Bacteriostatic / Bactericidal
Bactericidal
Penisilin - Sefalosporin
Aminoglikosid - Kotrimoksazol
Rifampisin - Isoniasid - dll

Bacteriostatic
Tetrasiklin - Kloramfenikol
Sulfonamid - Trimetoprim
Linkomisin - Klindamisin
PAS - dll
Faktor Pasien
Derajat infeksi
Mekanisme pertahanan tubuh
Farmakokinetika individual
. umur
. fungsi ginjal
. fungsi hati
Farmakogenetik
Prinsip Penggunaan Antibiotika

Diagnosa
Idealnya diagnosa bakteriologik

Tidak mungkin
ambil spesimens
sebelum terapi

Terapi antibiotika secepatnya

berdasarkan diagnosa klinik
(best guess)
. Apakah antibiotika diperlukan ?

. Pilih Antibiotika yang tepat

berdasarkan pertimbangan :
> spektrum
> resistensi kuman
> farmakokinetik
> bukti klinik
> sinergisme (untuk penggunaan kombinasi)
> harga
 Terapi Antimikroba
Empiric
Kuman belum teridentifikasi
broad spectrum
Definitive
Kuman dan Uji Kepekaan kuman sudah ada
narrow spectrum
Prophylactic or preventative
Mencegah jangkitan infeksi atau rekurensi
pasca infeksi
Pertimbangan Efek Samping
1. Reaksi alegi
2. Superinfeksi
3. interaksi obat

Pertimbangan :
- cara pemberian
- dosis
- frekuensi
- lama pemberian
Pertimbangan Penggunaan Obat Tambahan
misal :
. Probenicid
. Asam Klavulanat
. Sulbaktam
FARMAKOKINETIK / FARMAKODINAMIK
(PK/PD)
SEBAGAI INSTRUMEN KENDALI DALAM
TERAPI ANTIBIOTIK
Drug/PK/PD Factors
 Antibiotic Effect
Post Antibiotic Effect
PAE-Sub-MIC Effect
Post Antibiotic Lymphocyte Enhancement

Efek in vivo > in vitro

Concentration Depend. >> Time Depend.
 Post Antibiotic Effect
Post Antibiotic Effect (PAE) adalah istilah untuk
menjelaskan masih adanya efek penekanan
pertumbuhan bakteri setelah pemberian
antibiotik dihentikan
In vivo juga terjadi Postantibiotic sub-MIC effect
(PAE-SME) dan Postantibiotic Leucocytes
Enhancement Effect (PALE)
Efek PAE in-vivo biasanya lebih lama daripada
efek PAE in-vitro, terjadi karena adanya
tambahan efek PALE. Efek PAE in-vivo
aminoglikosida dan kuinolon terhadap baksil
gram negatif menjadi dua kali lipat efek in-vitro
 Post Antibiotic Effect
Post Antibiotic Effect sedang (moderate) sampai
lama (prolonged) terjadi pada
semua jenis antibiotik terhadap kuman
susceptible gram positif (stafilokokus dan
streptokokus)
antibiotik penghambat sintesa protein / as.
nukleat terhadap baksil gram negatif
Post Antibiotic Effect sedikit (short) atau tidak
ada sama sekali, terjadi pada pemberian
antibiotik beta-laktam (kecuali karbapenem)
terhadap baksil gram negatif
Killing Patterns Antibiotika
Pola 1: concentration-dependent killing
aminoglycosides, fluoroquinolones

Strategi penggunaan antibiotik dengan pola

concentration-dependent killing adalah:
Gunakan dosis maksimal / setinggi mungkin
yang dapat diterima penderita
Parameter paling berpengaruh di klinik
adalah Cmax/MIC atau AUC/MIC
Aplikasi klinik PK/PD penggunaan
antibiotik pola concentration-
dependent killing
CONC.

MIC
Time
Parameter PK/PD antibiotik dengan
pola concentration-dependent
killing :
AUC/MIC (perlu 125 untuk kuman Gram
negative dan 30 untuk kuman Gram
positive)
Cmax/MIC (perlu 8-10)
Pola 2: time-dependent killing
betalactams, macrolides

Strategi penggunaan antibiotik dengan pola

timedependent killing adalah:
Gunakan antibiotik dengan dosis minimal
dalam jangka waktu (durasi) yang maksimal
Parameter yang paling berpengaruh di klinik
adalah length of time of above-MIC
antibiotic blood level
 Aplikasi klinik PK/PD penggunaan
antibiotik pola time -dependent killing

CONC.
Continuous infusion

MIC

Time
Parameter PK/PD antibiotik dengan
pola time-dependent killing :

Time above MIC (perlu 40% of dosage

interval)
Konsentrasi antibiotik dalam darah cukup
4 x MIC
 Pola 1 Pola 2 Pola 3
Karakter - concentration - time dependent - time
P-Dinamik dependent - PAE minimal dependent
- PAE sedang sampai sedang - PAE lama
sampai lama
Jenis Aminoglikosida Beta laktam Tetrasilkin
Antibiotik Fluorokuinolon Makrolid Azitromisin
Metronidasol Klindamisin Glikopeptid
Amfoterisin B Oksazolidin Kuinopristin
Ketolid Flusitosin Flukonasol
Daptomisin
Dosing Maksimumkan Maksimumkan Optimalkan
Regimen dosis / duration of jumlah obat
konsentrasi exposure keseluruhan
obat
Parameter Peak Level dan Time above MIC AUC
P-Kinetik AUC
 Gentamicin concentration-time profile comparison of
conventional q8h intermittent dosing vs. once-daily dosing

20
Concentration (g/ml)

15
Once-daily regimen
10

Conventional regimen
5
MIC

6 12 18 24 Time (h)

(Kim & Nicolau, 2002)

Hasil terapi aminoglikosida menggunakan
pola daya bunuh antibiotika:

Efikasi klinik sama atau lebih baik

Bacterial killing meningkat
Toksisitas aminoglikosida berkurang
Mencegah terjadinya resistensi kuman
terhadap aminoglikosida dan kuinolon
Menurunkan biaya pengobatan
(Proctor, 1987; Rybak, 1999; Craig, 2002)
PROFIL KINETIK AMOXIL 250
Cmax = 4 mg/l
Kadar
T1/2 = 2 jam

Dari 4210,50,25 = 8 jam

4
KBM = 0,1 mg
NB: PAE ?
3

2
Perlukah dosis 500 mg ?
1

0 Waktu
1 2 3 4 5 6 7 8 9
AB Cyt. P-450 Related Interactions
(clinically significant)
Inhibits Cyt.P-450: Anticoagulants oral -- hypoprothromb.>
Carbamazepine toxicity -- >
Erythromycins Cisapride --Ventric. Arrhytmia
Fluconazole Digoxin bl.levels -- >>
Dilantin bl.levels -- <
Itraconazole Terfenadine -- Ventric. Arrhytmia
Theophylline bl.levels -- >
Ketoconazole Valproate bl.levels -- >

Induces Cyt. P-450: Anticoagulants -- hypothrombinaeia <

Chloramphenicol levels -- <
Rifampicin Contraceptives levels -- <
Corticoster. levels -- <
Cyclosporine levels -- <
 General Principles
Oral and Parental
Oral antibiotics must be able to survive stomach acid

Advantage: Ease and reduced cost

Disadvantage: Circuitous route, antibiotic passes to lower bowel

Parental antibiotics given by i.v.

Advantage: Direct route to site of infection

Disadvantage: Increased cost and need for qualified staff

 General Principles
Half-Lives
The length of time it takes for the activity of the drug to reduce
by half

Short half lives require frequent dosing

Old antibiotics have short half lives

New antibiotics may have half lives up to 33 hours

 General Principles
Combinations of antibiotics
Some antibiotics work better together than alone

Combining 2 or more drugs may be required to prevent the

emergence of resistance e.g. tuberculosis

Combinations should not be given when 1 drug would suffice

Antagonistic effects
No ability to adjust 1 drug concentration
PRINSIP UMUM PENGGUNAAN AB
DIDASARKAN RASIO MANFAAT
RISIKO
TEMPAT INFEKSI
SPEKTRUM AB ( INDIKASI)
SIFAT FARMAKOKINETIK AB, dll
EFEKTIVITAS KLINIS/ HASIL UJI KLINIS
PENGALAMAN KLINIS
KEAMANAN AB and MASKING EFFECT
POTENSI TIMBULNYA RESISTENSI
BIAYA OBAT
OBAT PADA SALURAN
PERNAFASAN
Nasal Decongestan
Sistemik, direk & indirek adrenergik agonis
pseudoephedrine
Topikal, -agonis
Oxymetazoline, naphazoline, phenilephrine
Antihistamin : CTM (Chlor Tyramin Maleat)
Antitusif
Sentral
Opiat : kodein, noskapin, dextrometorfan
Nonopiat : carbetapentane, caramiphen
Perifer : benzonatate
Ekspektoran : gliseril guaiacolate
Mukolitik :
 Dekongestan sistemik
Pseudoefedrin
Vasokonstriksi pembuluh darah mukosa
menurunkan kongesti hidung
KI: hipertensi, pasca infark miokard,
hipertiroid
 Dekongestan topikal
Oksimetazolin, nafazoline, fenilefrin
Vasokonstriksi pembuluh darah mukosa
menurunkan peradangan dan sumbatan
pada hidung
Efek samping
Rebound congestion
Irregular heartbeat
Headeache
Dizzines
Tremor
 Antihistamin
CTM
Mencegah histamin bekerja pada reseptor
H-1
Mencegah stimulasi refleks bersin
Efek antimuskarinik menurunkan sekresi
lendir dan meningkatkan dilatasi bronkus
Efek samping:
Paralisis gerakan cilia
Efek antikolinergik
Sedasi
Antitusif
 Antitusif
Kodein
Menekan batuk, analgesik
Kelemahan:
Rasa pahit
Mual & muntah
Menurunkan peristalsis konstipasi
Adiktif, euforia
Sebabkan pelepasan histamin
Overdosis: depresi nafas
 Antitusif
Noskapin, dekstrometorfan
Menekan batuk, tidak adiktif, kurang
menurunkan peristalsis
Kelemahan:
Tidak seefektif kodein
Sebabkan pelepasan histamin
Overdosis: efek halusinasi
 Antitusif
Carbetapentane, caramiphen,
chlorphedianol
Dosis kecil pada pediatrik yang
dikontraindikasikan menggunakan opiat
Kelemahan:
Efek antikolinergik
 Antitusif
Benzonatate

Menurunkan sensitivitas reseptor batuk

perifer
Kelemahan:
Confusion
Reaksi hipersensitifitas
Konvulsi
 Ekspektoran
Gliseril Guaiacolate
Merangsang iritan-reseptor di lambung, sebabkan
stimulasi parasimpatik pada saluran cerna dan saluran
nafas
Sebabkan sekresi mukus yang encer
Meningkatkan gerak cilia
Kelemahan : gangguan gastrointestinal
penggunaan pada anak ?
Obat lain:
Saponin (radix polygalae, radix primulae)
Obat Emetik (radix ipekak, emetin)
Amonium klorida, Kalium iodida
Minyak atsiri (menthol, eukaliptus, thymi,
 Mukolitik
Bromheksin & metabolitnya (ambroksol)
Menguraikan mukus: meningkatkan hidrolisis
lisosoma & stimulasi kelenjar mukus
Ambroksol merangsang produksi surfaktan,
menurunkan tegangan permukaan sehingga adesi
mukus pada bronkus menurun
 Mukolitik

Asetil sistein :
Menguraikan mukus: memutus ikatan disulfida
protein
Karbosistein:
Bekerja intrasel : pembentukan lendir encer
Obat-obat penyebab kelainan saluran nafas
Batuk : ACEi (kaptopril dll)
Serangan asma:
Reaksi anafilaksis obat
Beta antagonis / simpatolitik
Kolinomimetik (pilokarpin, piridostigmin)
Salisilat
Pentamidine nebulized
Propafenone
Prostaglandine f-2a
Tartrazine
Obat-obat penyebab kelainan saluran nafas
Acute pulmonary oedema / adult respiratory
distress syndrome
Beta agonis iv
Cytosine arabinoside
HCT
Nalokson
Analgesik narkotik
Salisilat
Trombolitik
Obat-obat penyebab kelainan saluran nafas
Emboli pulmonal
Kontrasepsi oral
Lupus like syndrome
Hidralazine
Fenitoin
Prokainamide
Interstitial pneumonia & fibrosis
Amiodarone
Obat sitotoksik / imunosupresif
Obat-obat penyebab kelainan saluran nafas
Depresi nafas
Alkolhol
Antidepresan
Antihistamin
Analgesik narkotik
Hipnotik sedatif (barbiturat & benzodiazepine)
Efusi pleura & fibrosis
Bromokriptin
Dantrolene
Methotrexate
Metisergid
Obat-obat penyebab kelainan saluran nafas
Infiltrasi akut & eosinofilia
Nitrofurantoin
Infiltrasi eosinofil kronik
Aspirin - Naproksen
Bleomisin - Penicillamine
Carbamazepine - Penisilin
Chlorpromazine (CPZ) - Fenitoin
Garam emas - Procarbazine
Imipramine - Sulfasalazine
Methotrexate - Sulfonamide
Asam Nalidiksat - Tetrasiklin