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Documenti di Professioni
Documenti di Cultura
Uun Sumardi
Selective Pressure
Antibiotic Resistance
Genetic Methods
[Phenotypic/Culture Result (S,R,I)]
Genotypic (Bio-molecular)
Intrinsic Resistance (Natural)
- It occurs naturally,
1. Lack target :
• No cell wall; innately resistant to penicillin
2. Innate efflux pumps:
• Drug blocked from entering cell or ↑ export of drug (does
not achieve adequate internal concentration). Eg. E. coli, P.
aeruginosa
3. Drug inactivation:
• Cephalosporinase, Betalactamase (Enzyme.) as in
Klebsiella pneumoniae ESBL, CRAB
Acquired resistance
1. Mutations
• It refers to the change in DNA structure of the gene.
• Occurs at a frequency of one per ten million cells.
• Mycobacterium tuberculosis, Mycobacterium lepra,
MRSA.
• Often mutants have reduced susceptibility.
Acquired resistance
2. Plasmid
• Extra chromosomal genetic elements can replicate
independently and freely in cytoplasm.
• Plasmids which carry genes resistant (r-genes) are
called R-plasmids.
• These r-genes can be readily transferred from one R-
plasmid to another plasmid or to chromosome.
• Much of the drug resistance encountered in clinical
practice is plasmid mediated
Gram Positive vs Gram Negative Bacteria
Bad Bug
MDR A baumannii
MDR P aeruginosa
S aureus A baumannii Enterobacter
spp.
MRSA
MDRSH
IDSA.2004.
BAD BUG in Internal Medicine Dept.
Dr. Hasan Sadikin Hospital,2012 (n=1.121).
Fungal
Bad Bug
Acromobacter spp ""$
Gram negatif
Enterobacteriaceae
Pseudomonas spp !#!$
&$ #&$ *&$ )&$ "&$ !&&$ !#&$ !*&$ !)&$ !"&$ #&&$
Super Bug Aetiology in Sepsis Patient, Internal Med. Dept.,
MIC Room, RSUP Dr. Hasan Sadikin, 2013 (n=152)
CRAB’s
CRPsA’s
NDM’s
KPC’s
ug
r B
up e
S
27 February 2017 | GENEVA - WHO today published its first ever list of antibiotic-resistant "priority pathogens" – a catalogue of 12 families
of bacteria that pose the greatest threat to human health.
Mechanisms for Carbapenem Resistance in Super Bug
Bacterial Pathogen
Enzymes
Pediatr Infect Dis J. 2011; 30(12):1094-5. Int J Med Microbiol 2010;300(6)371-9. N Engl J Med. 2008;20;358(12):1271-81.
Initiative Action Plan on Antimicrobial Resistance
2015 2017
Indonesia NAP on Antimicrobial Resistance
WHO, 2017.
add.4. Optimise use of antimicrobial
WHO, 2017.
HAP in RSUP dr. Hasan Sadikin, Bandung.
PPRA
RSUP dr. Hasan Sadikin,
2017
PPA/ASP RSUP Dr. Hasan Sadikin Model
Pemilihan Antimikroba
Optimasi Dosis
Right Diagnosis,
Perubahan Pemberian Konversi Antimikroba
Antimikroba Right Drugs, IV-PO
Right Doses,
PPA/ASP
Permintaan
Antimikroba
Right Dosing,
RSUP
Surveilans &
Umpan Balik
Right Duration,
RSHS
IT
Restriksi =“5D” in Audit (Prospektif) &
Antimicrobial
Preotorisasi
Strategi Utama Stewardship Program/
Umpan Balik
Strategi Utama
PPA, , 2016
PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 2406/MENKES/PER/XII/2011
PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 8 TAHUN 2015
PPRA.SK.Direktur Utama, RSUP Dr. Hasan Sadikin, 2015
Restriksi dan Preotorisasi Antimikroba RSUP dr.Hasan Sadikin
Kategori III, adalah antimikroba yang membutuhkan persetujuan sebelum antimikroba tersebut boleh
diresepkan. Persejutuan diberikan oleh konsultan spesifik di SMF jika telah memenuhi kriteria.
Kategori II, adalah antimikroba yang hanya boleh diresepkan atas indikasi spesifik yang kemudian ditinjau
oleh Tim PPRA dalam kurun waktu 3 hari kerja.
PPA, , 2016
PPRA
RSUP dr. Hasan Sadikin,
2017
Formulir Permintaan Antimikroba
PPRA
RSUP dr. Hasan Sadikin,
2017
First Study
Blood Cultures Result in Sepsis Patients, Pre and Post PPA
[Pra PPA Januari-Maret (n=55), Post PPA April-Juli 2016 (n=57) di 4 Ruang Intermediate dan 1 Intensive]
A Felani, U Sumardi, I Parwati. The Difference of Defined Daily Doses and Cost of Ceftriaxone Therapy Before and After Antimicrobial Stewardship Programmed In
Critically Ill Patients. Thesis 2016.
Capaian Kinerja Tim PPRA Tahun 2017
A. Penggunaan Antimikroba
No KPI Target Capaian
- BEDAH = 78 %
- IPD = 47.75 %
6.000
4.000
- 68.263.000 IDR
2.467
2.000
32.071.000 IDR
0
Januari Februari Maret April Mei Juni Juli Agustus September Oktober
270.800.000 IDR
14.000 13.540
41.13%
10.572
10.500
159.400.000 IDR
7.970
11.832 5.219
7.000 1.464
1.694
1.427
3.500
238 4.812
RAWAT INAP 3.926
ODS
COT
1.470
-
2015 2016 2017
Director/Chief
Medical Officer P&T
Information (CMO)
Committee
Technology (TFT)
Infection
Medical
Prevention Information
(PPI) ASP
ARCP Systems
Coordinators Leader
RSUP dr Hasan Sadikin
(Qualitative,Quantitative,
Infectious
Resistance,Education)
Diseases
Nursing Care
Microbiology
Clinical
Laboratory Partners in Optimizing
Pharmacy
ASP~Dept./SMF
Specialists
Decentralized
Pharmacy
Specialist
Modified from : Dellit TH et al. Clin lnfect Dis. 2007;44:159-177.
PPA/ASP. RSUP dr Hasan Sadikin Bandung. 2016
Indikator Mutu PPA/ASP Model RSUP Dr. Hasan Sadikin, Bandung,
2018.
No Indikator Target
Antibiotic Use:
- Restriction/Preauthorisation
- Quantitatives
- Qualitatives
Cmax/MIC
40
Concentration (mg/L)
30 Tigecycline
20 AUC/MIC
10 MIC
PAE
0
0 0.5 8 12 16 24
H J Morrill, J M Pogue, K S Kaye, K L LaPlante. Treatment Options for Carbapenem-Resistant Enterobacteriaceae Infections. OFID, 2015.
Algorithm for antibiotic choice in patient with bacteriaemia of
carbapenem resistant Enterobacteriaceae (CRE).
F Alhashem, N L Tiren-Verbeet, E Alp, M Doganay.Treatment of sepsis: What is the antibiotic choice in bacteremia due to carbapenem
resistant Enterobacteriaceae? .World J Clin Cases. 2017; 5(8): 324-332.
Summary
•
AMR is the main problem for antibiotic treatment.
•
ASP can improve cost effectively in antibiotic treatment.
•
ASP continuing with Prospective audit, Intervention and Feedback.
•
ASP is the solution for Combating Resistant Antibiotic Bacterial.
•
ASP with Pharmacies can do better.
Singapore Antimicrobial Stewardship Training Course,
at Tan Tock Seng Hospital August 2017.
Anti-Microbial Resistance (AMR)
Algemeene Bandoengsche Ziekenhuis, 1923.
Gemeente Ziekenhuis Juliana, 1927.
Thank You