Curriculum Vitae

Nama : Dr. Ronald Irwanto Natadidjaja, SpPD – KPTI, FINASIM

Pendidikan :
SMP - SMA : Kolese KANISIUS, lulus 1994
Dokter Umum : FK TRISAKTI, lulus 2002
Spesialis Penyakit Dalam (Internist) : FKUI, lulus 2009
Konsultan / Subspesialis Penyakit Tropik & Infeksi : FKUI / PAPDI, lulus 2013

Pekerjaan :
Bendahara Pengurus Besar Perhimpunan Konsultan Penyakit Tropik dan Infeksi Indonesia (PB PETRI)

SekJen Pengurus Pusat Perhimpunan Pengendalian Infeksi Indonesia (PP. PERDALIN)

Tim Panel Ahli PNPK Sepsis, Kemenkes RI

Anggota Pokja PPI, Kemenkes RI

Kepala Bagian Ilmu Penyakit Dalam, FK TRISAKTI

Ketua PPRA, RS PONDOK INDAH – PURI INDAH dan RS PONDOK INDAH – BINTARO JAYA

Wakil Ketua Komite Medik, RS PONDOK INDAH – PURI INDAH

Internist - Konsultan, RS PONDOK INDAH – PURI INDAH dan RS PONDOK INDAH – BINTARO JAYA
Antimicrobial Stewardship Fact and Needs :
RASPRO Research and Report

Ronald Irwanto
Internist-Infectious Disease (ID) Specialist
Indonesian Society of Infection Control (INASIC)
ASP Fact and Regulation
 Antimicrobial Stewardship in Australian
Health Care 2018
AMS aims to minimize the unnecessary use of
antimicrobials and promote the appropriateness
of antimicrobial prescribing, resulting in
improved patient outcomes, cost-effective
therapy and reduced adverse consequences of
antimicrobial use, including AMR.
McGowan JE. Antimicrobial stewardship: the state of the art in 2011 – focus on outcome
and methods. Infect Control Hosp Epidemiol 2012;33(4):331–7. 7.

MacDougall C, Polk R. Antimicrobial stewardship programs in health care systems. Clin

Microbiol Rev 2005;18(4):638–56.
 Antimicrobial Stewardship in Australian
Health Care 2018
It is sometimes difficult to draw a direct
relationship between system interventions
and their effects. In the hospital sector, many
of the studies of the efficacy of AMS have
reported on structural and process measures
(such as the presence of guidelines and
reduction in antimicrobial use)
McGowan JE. Antimicrobial stewardship: the state of the art in 2011 – focus on outcome
and methods. Infect Control Hosp Epidemiol 2012;33(4):331–7. 7.

MacDougall C, Polk R. Antimicrobial stewardship programs in health care systems. Clin

Microbiol Rev 2005;18(4):638–56.
 Ronald Irwanto Antimicrobial Stewardship Program (RASPRO) Indonesia

MIC-90
Dosis minimal yang dapat digunakan untuk mencegah
pertumbuhan 90% kuman IN VITRO (Standard CLSI )

RESISTENRELATIF

Contoh/
Cut off MIC-90 Resisten betalaktam = 32ug/ml

E.coli dinyatakan RESISTEN terhadap betalaktam apabila diberikan 32ug/ml

Beta Laktam IN VITRO BELUM BISA MENGHAMBAT PERTUMBUHAN 90%

QUESTION :
Bila diberikan AB 34ug/ml36ug/ml 38ug/ml SENSITIF

IN VIVO :
Diberikan 1x2 gram Ceftriaxone Resisten Diberikan 2x2g 3x2gSENSITIF??
 Mechanism of Antimicrobial Resistance:
“Selective Pressure” for Antimicrobial-Resistant Strains

Resistant Strains
Rare
Antimicrobial
Exposure

Resistant Strains
Dominant

Campaign to Prevent Antimicrobial Resistance in Healthcare

Settings, CDC 2002
 PERMENKES 8 / 2015
BAB II
STRATEGI
Pasal 3
Strategi Program Pengendalian Resistensi Antimikroba dilakukan dengan cara:
a. mengendalikan berkembangnya mikroba resisten akibat tekanan seleksi
oleh antibiotik, melalui penggunaan antibiotik secara bijak; dan
b. mencegah penyebaran mikroba resisten melalui peningkatan ketaatan
terhadap prinsip pencegahan dan pengendalian infeksi.

PERDALIN- RASPRO : perpanjangan teori selective pressure (tekanan

selektif) yang diejawantahkan dalam bentuk implementasi flowcart yang
memandu klinisi kapan menggunakan antibiotik spektrum luas dan kapan
menggunakan antibiotik spektrum sempit
Empirical Prediction :
Aliberti, Shorr Score, Tumbarelo et al, Duke, Gomila et al, Carmeli conc.
 Bagian
PERMENKES 8 / 2015 Kesatu
Umum
Pasal 6
(1) Setiap rumah sakit harus melaksanakan Program Pengendalian Resistensi Antimikroba
secara optimal.
(2) Pelaksanaan Program Pengendalian Resistensi Antimikroba sebagaimana dimaksud
pada ayat (1) dilakukan melalui:
Pembentukan
a.pembentukan tim pelaksana PPRA RSResistensi Antimikroba;
program Pengendalian
b.penyusunan kebijakanPPAB / Antibiotic
dan panduan Guidelines
penggunaan antibiotik;
PPI dan
c.melaksanakan penggunaan antibiotik PPRA
secara bijak;
d.melaksanakan prinsip pencegahanImplementasi
pengendalian infeksi.
(3) Pembentukan tim pelaksana Program Evaluasi
Pengendalian Resistensi Antimikroba rumah
sakit sebagaimana dimaksud pada ayat (2) huruf a bertujuan menerapkan Program
Pengendalian Resistensi Antimikroba di Rumah Sakit melalui perencanaan,
pengorganisasian, pelaksanaan, monitoring, dan evaluasi.
(4) Penyusunan kebijakan dan panduan penggunaan antibiotik, melaksanakan
penggunaan antibiotik secara bijak, dan melaksanakan prinsip pencegahan
pengendalian infeksi sebagaimana dimaksud pada ayat (2) huruf b, huruf c, dan huruf
d dilakukan sesuai dengan ketentuan peraturan perundang-undangan.
Pasal 7-10 tentang Pembentukan PPRA RS dan Tugas-Tugasnya
 PERMENKES 8 / 2015
Indikator Mutu
Pasal 11
Indikator mutu Program Pengendalian Resistensi Antimikroba di Rumah Sakit
meliputi:
a. perbaikan kuantitasDDDpenggunaan antibiotik;
b. perbaikan kualitas penggunaan antibiotik;
Gyssens
Pola Kuman-HAIs
c. perbaikan pola kepekaan Incidence
antibiotik dan penurunan pola resistensi
Case Report multidisiplin
antimikroba;
d. penurunan angka kejadian infeksi di rumah sakit yang disebabkan oleh
mikroba multiresisten; dan
e. peningkatan mutu penanganan kasus infeksi secara multidisiplin, melalui
forum kajian kasus infeksi terintegrasi.
The RASPRO Research :
ASP Needs
Pattern of Skin & Soft tissue infection microorganism
aken from 3 emergency room in Jakarta
Ronald Irwanto (INASIC), Suhendro, Khie Chen, Yeva Rosana
Published in poster session, ISAAR, Bangkok 2009
Pola Resistensi dan Uji Kepekan Mikroorganmisme Gram Positif pada Infeksi Jaringan Lunak
Komplikata diTiga IGD Rumah Sakit di Jakarta
Ronald Irwanto1, Suhendro2, Khie Chen2, Yeva Rosana3
Published Indonesian Antimicrobial Resistant Watch (IARW (2009)
Culture-and non culture-based antibiotics for complicated
soft tissue infections are comparable
Ronald Irwanto (INASIC) , Suhendro, Khie Chen, Murdani Abdullah
Published in Universa Medicina 2013 : 32(1) : 20-28
Antibiotic treatment based on Guidelines for Reducing Length of Stay
(LOS) in Patients with Community Acquired Pneumonia
FC. Munarsih, Ronald Irwanto (INASIC), Syamsudin
Published in Jurnal Penyakit Dalam Indonesia
Indonesian Journal of Internal Medicine 2018 : 5(3) : 141-8
Hubungan antara Kadar Procalcitonin dengan Serum Transaminase pada
Pasien Sepsis : Sebuah Studi Pendahuluan
Nurhadi Kuswoyo, Ronald Irwanto
published in Journal Biomedkes 2019 : 2 (1) : 15-19
RASPRO Concept : How Indonesian Private Hospital Run the ASP?
Ronald Irwanto
Asia Pacific Society of Infection Control Congress, Da Nang, Vietnam 2019
Survey Persepsi terhadap Kebutuhan dan Kesulitan Rumah Sakit dalam
Menjalankan Fungsi Panitia Pengendalian Resistensi Antibiotik
Ronald Irwanto, Djoko Widodo,, Aziza Ariyani, Hadianti Adlani
Journal of Hospital Accreditation 2019 :1(2) : 36-40
Decreasing the Broad Spectrum Antibiotics Unit Sold:
The Prospective Antimicrobial Stewardship of RASPRO Indonesia Model
Ronald Irwanto Natadidjaja*#, Yuhana Fitra**, Yudianto Budi Saroyo**,
Augustine Matatula**, Rinna W Sundariningrum**
J Antimicrobiol Resist & Inf Control. 2019 Suppl 1 : 148 : 147(357)

In Progress Publication
Konsep RASPRO : Upaya menjalankan amanah PERMENKES 8 / 2015 dalam Kajian
SNARS edisi 1 / 2018 (Komparasi 2 rumah sakit)
Ronald Irwanto, Yuhana Fitra, Aziza Ariyani, Rika Bur
In progress publication Journal of Hospital Accreditaion 2020
Empiric prediction to culture : RASPRO Model by Patient Risk
Ronald Irwanto, Djoko Widodo, Hadi Sumarsono
In progress publication
Evaluasi Kualitatif Penggunaan Antibiotik Pasien Paru Non Tb
Salah Satu Rumah Sakit Swasta Di Bandung
Louis Madalena, Elin Yulinah , Marwan Awaloeddin, Ronald Irwanto
In Progress Publication Journal Farmasi Indonesia
Ronald Irwanto- Internist-Infectious Disease (ID) Consultant
Ronald Irwanto- Internist-Infectious Disease (ID) Consultant
 J Biomed Kesehat 2019 : 2 (1) : 15-19

Ronald Irwanto- Internist-Infectious Disease (ID) Consultant

Ronald Irwanto- Internist-Infectious Disease (ID) Consultant
Ronald Irwanto- Internist-Infectious Disease (ID) Consultant
RASPRO Overview Concept
 www.rasproindonesia.com
Ronald Irwanto Antimicrobial Stewardship Program (RASPRO) Indonesia

RASPRO Core Concept

Hospital
Clinician
/ Patient Safety
Insight
AGREEMENT Insight

Individual Community
ANTIMICROBIAL Approach
Approach
STEWARDSHIP PROGRAM

Antimicrobial Stewardship program is not about how to

restrict the broad spectrum but how to use antibiotic in
good!!
Ronald Irwanto, Hadi Sumarsono, RASPRO, RSPI Puri Indah,2013
What is RASPRO?
Protected by
KEMENKUMHAM RI No. 000121541
Intelectual Property Rights /
Hak Kekayaan Intelektual dilindungi
Undang-undang no.28 Pasal 72 / 2014
RASPRO is a concept for running ASP,
born in Pondok Indah-Puri Indah
hospital, a private hospital in Jakarta,
started in 2013
We, the team
noted all data and difficulties found in
field. Next, we did a further
discussion and synthesized more than
100 academic journals on all the
problem found,and formulating “THE
RULE of 3 PIE” as a conclusion for
implementing the ASP in hospital .
And, we implement it.
We do :
FIX & OUT in running this program due to
the actual situation
Predicting The MDR in Pneumonia
The ARUC Prediction
HCAP criteria (at least one of the following):
Previous hospitalization (3 months),
dialysis,
i.v. therapy previous 30 days,
residence in nursing home or long-term care facility

Bilateral Pulmonary Infiltration

Pleural effusion
PaO2/FiO2 < 300
 A score for predicting the risk of infection with resistant bacteria, including factors related to contact with the
healthcare environment as well as patients’ comorbidities, was computed (Table 4). The scores ranged from 0
to 12.5. Based on visual inspection, patients were grouped into low-risk and high-risk classes as a function of
their overall score (Figure 1). Among patients with a score ≤0.5 on entry, the prevalence of a resistant bacteria
was 8% (95% CI, 2%–13%), compared with 38% (95% CI, 25%–50%) in those with a score of ≥3 (P < .001). Figure
2 depicts the ROC curve for the score. The area under the ROC curve is 0.79 (95% CI, .71–.87). A score >0.5 was
associated with the best balance between sensitivity (0.75) and specificity (0.71).
Variable  Score 

No risk factors for MDR pathogen (including

0 
comorbidities) 

≥1 of the following: cerebrovascular disease, ALIBERTI SCORE :

Risk MDR Pathogen
diabetes, COPD, antimicrobial therapy in
preceding 90 days, immunosuppression, home 0.5 
wound care, home infusion therapy (including
antibiotics)  in Pneumonia

Residence in a nursing home or extended-care

3 
facility 

Hospitalization for ≥2 days in the preceding 90

4 
days 
Chronic renal failure  5 
 Gomila et al : Empiric Prediction of the
MDR in UTI
Gomila A et al dalam prediksi MDR pada infeksi saluran kemih
mempertimbangkan
- penggunaan antibiotik dalam < 30 hari
- penggunaan urin kateter, riwayat perawatan < 30 hari
- tindakan invasif < 30 hari
- jenis kelamin laki-laki
- serta riwayat infeksi saluran kemih dalam 1 tahun terakhir.

Gomila A, Shaw E, Carratala J. Predictive factors for multi-drug resistant gram negative
bacteria among hospitalized patients with complicated urinary tract infections.
Antimicrob Resist and Inf Contr, 2018 ;7:111
 Utility of a Clinical Risk Factor Scoring Model in Predicting Infection with
Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae on
Hospital Admission
Steven W. Johnson, PharmD,1,2 Deverick J. Anderson, MD, MPH,1 D. Byron May, PharmD,1,2
and Richard H. Drew, PharmD, MS1,2

• Italian Model (Tumbarello et al5)

Attribute No. of points

• Recent antibiotic therapy with β-lactams

< 90 days
and/or fluoroquinolonesa 2
• Previous hospitalizationb 3
• Transfer from another healthcare facility 3
• Charlson Comorbidity Score of ≥4 2
• Recent history of urinary catheterizationc 2
• Age ≥70 years 2

aDuring the 3 months preceding the index hospitalization. Infect Control Hosp
bDuring the 12 months preceding the index hospitalization. Epidemiol. 2013
cDuring the 30 days preceding the index admission. Apr; 34(4): 385–392.
 Utility of a Clinical Risk Factor Scoring Model in Predicting Infection with
Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae on
Hospital Admission
Steven W. Johnson, PharmD,1,2 Deverick J. Anderson, MD, MPH,1 D. Byron May, PharmD,1,2
and Richard H. Drew, PharmD, MS1,2

Duke Model
Attribute No. of points
Recent antibiotic therapy with β-lactams 3 < 90 days
and/or fluoroquinolonesa

Previous hospitalizationb 2

Transfer from another healthcare facility 4

Recent history of urinary catheterizationc 5

Immunosuppressiond 2 < 90 days

a
During the 3 months preceding the index hospitalization. Infect Control Hosp
b
During the 12 months preceding the index hospitalization. Epidemiol. 2013
c
During the 30 days preceding the index admission. Apr; 34(4): 385–392.
d
During the 3 months preceding the index admission.
Y. Carmeli,2014
 Carmeli Y Conclusion, 2014

Collateral Damage
 PINK BOX PURPLE BOX PEACH BOX

1. Promoting Guidelines (3) 2. Implementation (3) : 3. Evaluation (3) :

1. Disease Severity and 1. Strengthening Knowledge 1. Host :
Risk (Carmeli Conclusion) 1. Workshop 1. Hospital Stay
1. Type 1 2. Socialization 2. Cost
2. Type 2 3. Discussion 3. Mortality
3. Type 3 2. Controlling the Socio-Behavioral 2. Agent :
2. Antibiotic PK/PD 1. Credential 1. MDR-HAIs Incidence
1. Dose 2. Re-credential 2. Patient Colonization
2. Track 3. Restriction Program / 3. Environment
Consultation Regulation Colonization3.
3. Tissue Penetration
3. System (IT) 3. Compliance :
3. Microorganism Pattern
1. Guidelines breakdown 1. Define Daily Dose
1. Layer 1 : 3 T
(Quantitative)
1. Timing 2. IT / Bridging Flowchart
2. Technique 3. Guidance & Discussion
2. Gyssens
3. Transport
(Qualitative)
2. Layer 2 : 3 C
1. CLSI THE RULE of 3 PIE 3. Case Report
2. Completing plate
(Sporadic)
3. Completing MIC-90
Ronald Irwanto Antimicrobial
3. Layer 3 : 3 P
Stewardship Program (RASPRO) File
1. Proper Setting
RSPI-PURI INDAH
2. Proper Size
Copyright
3. Proper Percentage
ARUC Score
Alberti et al

Tumbarelo Model
Duke Model
Infect Control Hosp
Epidemiol. 2013 :34(4): 385–392.

Gomila et al

Gomila A, Shaw E,
Carratala J. Predictive
factors for multi-drug
resistant gram
negativebacteria among
hospitalized patients with
complicated urinary tract
infections.
Antimicrob Resist and Inf
Contr, 2018 ;7:111

Carmeli conclusion
etc

Hak Cipta :
RASPRO Indonesia
Hak Cipta : RASPRO Indonesia
RASPRO Alur Antibiotik Lanjutan (RASLAN)

RASPRO
Indonesia
Formulir RASPRAJA
Formulir RASPRAJA (sambungan)
 Formulir Antibiotik Sesuai Kultur
(RASPATUR)
Ketentuan : Formulir diisi apabila antibiotik akan
diberikan sesuai kultur

Nama Pasien :
Nomor RM :

Antibiotik diberikan sesuai sensitifitas kultur kuman:

1.
2.
Nama : DPJP :

Mulai x/ Antibiotik 1 2 3 4 5 6 7
hari

Administering
RASAL Time

RASLAN Administering
Time
RASPRAJA

RASPRO Nurse Cardex

If >7 days
RASLAN Administering
Time

RASPATUR Administering
Time

For Watching the RASPRO Form

“Traffic”
Done for each Patient
Hak Cipta : RASPRO Indonesia
 Pemberian
Ruang
Nama Pasien Antibiotik Mulai Harus STOP tgl RASAL RASLAN RASPATURRASPRAJA
tgl (7 hari dari Alasan
tgl mulai) Berkepanjangan

RASPRO Pharmacist Cardex

For Watching the RASPRO Form

“Traffic”
Done for each Patient
Hak Cipta : RASPRO Indonesia
 PINK BOX PURPLE BOX PEACH BOX
PROMOTING IMPLEMENTATION EVALUATION
Guidelines Guidelines
Patient Watched by RASPRO Nurse CARDEX
Stratification (For Each Patient) Host
Type I
Type II
Type III AB
First AB Change or Add Prescription
>7 Days Micro
Prescription AB Prescription By Culture
Antibiotic Culture AB Usage
PK/PD Organism
Taking
RASLAN
-Dose Form
-Track RASAL RASLAN RASPATUR
RASPRAJA FORM
-Tissue Form Form Form /
Penetration AUTOMATIC Antibiotic
Stop Order Compliance
Cumulative
Antibiogram Restrict when it’s not DDD
-Timing proper to the RASPRO Gyssens
- Complete Stratification Integrative
--Proper Watched by RASPRO Pharmacist CARDEX Case Report
(For Each Patient)
Study and Result
 Decreasing the Broad Spectrum Antibiotics Unit Sold:
The Prospective Antimicrobial Stewardship of RASPRO Model in
A Private Hospital, Indonesia
Ronald Irwanto Natadidjaja*#, Yuhana Fitra**, Yudianto Budi Saroyo**,
Augustine Matatula**, Rinna Wamila Sundariningrum
Results.
Three months observation and comparison before-after RASPRO-RASAL
flowchart implemented :
0.5g Meropenem unit sold decreased 63.83%, 1g Meropenem decreased 75.42%
while Imipenem showed 100% reduction.
A 93.80% decreasing of Ceftazidime and 70.05% Cefepime unit sold also reported.
Overall, we noted 76.10% broad spectrum reduced before-after RASPRO-RASAL
implemented.
Conclusion.
Decreasing of broad spectrum antibiotics unit sold was reported in 3 months after
RASPRO-RASAL used.
This result might not be a fully improvement of RASPRO-RASAL tools, but in
our experience and opinion, this significant result should be considered as part of
RASPRO-RASAL implementation.
J Antimicrobiol Resist & Inf Control. 2019. 8(suppl 1) : P357
 Private Hospital In Indonesia :
Pre-Post RASPRO
Three Months Comparison of Broad Antibiotics Unit Sold: Before and After RASPRO-RASAL Criteria Implemented
960
1000
900
800
700
600
500
Jul-Sep 2018
400
236 Oct-Dec 2018
300 197
200 129
100
47 17 6 8
59
0
0

J Antimicrobiol Resist & Inf Control. 2019. 8(suppl 1) : P357

 Private Hospital In Indonesia :
Pre-Post RASPRO

Total Broad Spectrum Antibiotics Unit Sold :

Before and After RASPRO-RASAL Implemented

1400

1200

1000

800

600

400

200

0 1339 320
3 Months Before (Jul-Sep 2018) 3 Months After (Oct-Dec 2018)
J Antimicrobiol Resist & Inf Control. 2019. 8(suppl 1) : P357
 2017 2018- Now
PPAB Kedua Workshop PERDALIN ARTS 7 angkatan
2015 RSPI Puri Indah
PPAB Pertama diluncurkan Pembentukan Komunitas ARTS
2013 RSPI Puri Indah berdasar pola kuman (saat ini > 400 anggota dokter &
Penulisan awal diluncurkan dengan cut off Pa
berdasar pola kuman
dokter spesialis)
Konsep PPRA dan Ab +
dengan cut off Pa Stratifikasi pada infeksi besar Bimtek 21 Rumah Sakit
dan Ab

RASPRO
Oral Presentation APSIC, Vietnam
PP.PERDALIN setuju Abstract data RS.Puri Indah
untuk share
2014 1 orang mahasiswa S2 lulus dari ITB
2016 model PPRA di RSPI
Konsep PPRA 2018 dengan tesis menggunakan unsur
disempurnakan Uji PPAB dengan Workshop PPRA
LOS pasien CAP PERDALIN ARTS
Algoritma RASPRO
RSPI Puri Indah Model PPRA On Going Process Publication
diuji sebagai Tesis S2 Di-hakcipta-kan
Di Univ.Pancasila dengan nama 2 orang mahasiswa S2 sedang dan 1
Published di JPDI RASPRO fellow subspesialis
menulis tesis menggunakan unsur
Presentasi RASPRO RASPRO
pada ICPIC, Geneva., Swiss,
APID2019 pre-post study RASPRO
Bangkok
Technical Guidance for PERDALIN-RASPRO Implementation has
been done in a few hospitals in Indonesia both Private &
Government
JAKARTA Province of West Sumatera
National Cardiac Center Harapan Kita Hospital National Stroke Bukit Tinggi Hospital
Tebet Government General Hospital
Cempaka Putih Government General Hospital Province of West Java
Pasar Rebo Government General Hospital Bandung Adventist Hospital
Hermina Group Hospitals Immanuel Hospital
Koja Government General Hospital Sayang Hospital, Cianjur
Cicendo National Eye Center
Banten Syamsudin Government General Hospital
AwalBros Hospital
Papua Province of Jambi
Abepura Hospital HAMBA Government General Hospital

Province of East Borneo Province of East Java

AW.Sjahranie Government General Hospital Soedono Government General Hospital Madiun
Sudomo, Government General Hospital, Trenggalek
Province of Central Java Syamrabu Government Hospital, Bangkalan
Mardi Rahayu Hospital, Kudus
Tjitrowardojo Government General Hospital, Purworejo
 Terima Kasih
www.rasproindonesia.com