Twelve Desirable Attributes for Computer-based Patient Records (Adapted from the Institute of Medicine's Task Force on Computer-based

Records)1

A CPR should:
Contain problem lists Support recording health status and functional level State the logical basis for all diagnoses and conclusions Be able to be linked to other clinical patient records Address comprehensively patient information confidentiality Be accessible in a timely manner by all who have authorized access Allow selective retrieval and formatting of information by users

Be linked to local and remote knowledge, literature, and administrative databases

Provide decision analysis tools, clinical reminders, and prognostic risk assessment Use a defined vocabulary and support structured data Help providers and institutions manage and evaluate quality and costs Be flexible and expandable to meet future needs

Content of presentation
Introduction Global trends in antimicrobial resistance Essential medicines and antimicrobial resistance
Irrational use Access Quality
Infectious diseases Other areas of concern

 Regional situation

Content of presentation
Status of antimicrobial resistance (AMR) Assessment of economic impact

Policy options Recommendations

Introduction
Antimicrobial resistance is both a natural phenomenon and a major global threat to public health
Through replication and conjugation by jumping plasmids Observed soon after introduction of penicillin

Introduction
The link between antimicrobial resistance development and inappropriate use of antimicrobials in humans and animals is acknowledged
Health Assembly resolution WHA51.17 (1998) Regional Taskforce on Antimicrobial Resistance (2000) WHO Global Strategy for Containment of Antimicrobial Resistance (2001) Regional Consultative Committee (2002)

Global trends: Infectious diseases

Infectious diseases still account for 45% of deaths in low-income countries

Acute respiratory infections 3.5 million killed globally (1998)

Influenza and pneumonia

Diarrhoea 2.2 million killed globally (1998)

E. coli, shigellosis, cholera Lack of testing for antibiotic sensitivity during outbreaks

Global trends: Infectious diseases Infectious diseases still account for

45% of deaths in low-income countries

HIV/AIDS
Malaria
Resistance to multidrug therapy

Tuberculosis

Chloroquine no longer effective in 81 of 92 countries

? 20% of resistant new tuberculosis cases are multidrug resistant Cost implications

Global trends: Nosocomial infections

Intensity of use of antimicrobials in hospitals Increasing resistance of highly virulent strains (Staphylococcus aureus) Hospital acquired infections (mainly drug resistant microbes) account for significant death rates and numbers
40 000 deaths/year in USA

Global trends: Food production

About half of all antibiotics produced are used for farming Reports indicate that 50% of human antimicrobial resistance is caused by growth promoters in livestock Where growth promoters are phased out, antimicrobial resistance in livestock drops dramatically

Medicines: (ir)rational use

25%75% of antibiotic prescriptions inappropriate
Empirical treatment, lack of diagnostic services Lack of targeted education

50%90% bought privately from community pharmacy;

half for 1-day treatment

Medicines: Between 1975 and 1997 Access 1223 new compounds launched
only 11 for tropical diseases

Multitude of problems:
Drug pipeline
65 60 55 50

New products (number)

R&D expenditure (US$ billions)

40 35 30 25 20

45 15 40 35 10 5

30 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Medicines: Access

Multitude of problems:
Drug pipeline

Focus on large markets

Medicines Access

Percentage of population with regular access to essential drugs

EMR Less countries than 50% 4 5080% 4 80- More than 95% 95% 6 8

Multitude of problems:
Drug pipeline Focus on large markets Geographical inequities Financial inequities

More than 100 million people in the Region do not have regular access to essential drugs;
Problem not only found in the low income countries

Medicines: Quality
Quality and safety standards exist, enforcement varies greatly:

not all countries have well-functioning drug regulatory systems 10%20% of drugs fail quality testing substandard and counterfeit drugs continue to kill

Medicines: Quality
Quality and safety standards exist, Incorrect Ingredient 16 % enforcement varies greatly: Incorrect

not all countries have well-functioning drug regulatory systems 10%20% of drugs fail quality testing substandard and counterfeit drugs continue to kill

Incorrect 17 % amount 17%

Amount

ingredient 16%

Other 7%

No 59 %

No active ingredient Ingredient 60%

Regional trends: Health implications

Similarity in terms of scope and magnitude of the problem Link between antimicrobial resistance and irrational use of medicines is established in various studies High levels of drug resistance are found throughout the region for medicines used in common infectious diseases
Tuberculosis, acute respiratory infections, urinary tract infections, malaria, etc.

Regional trends: Health implications

Multidrug resistance is commonly found Need to underpin treatment choice with laboratory tests Need for time-series to determine trends
Wide availability of antimicrobials Widespread use of new generation antimicrobials Antimicrobial resistance is increasing in the

World

Regional trends: Economic implications

Cost of ARI, diarrhoea, tuberculosis and malaria treatment
Total morbidity

Total cost of treatment

First line Second line Third line

First line Second line Third line

Regional trends: Economic implications

Cost of tuberculosis treatment
TB morbidity

Cost of TB treatment

Chine India Indonesia

First line Second line Third line

First line Second line Third line

Policy & strategy options

Addressing antimicrobial resistance requires a comprehensive multisectoral approach
Target audience
Government (health systems) Patients and the general community Prescribers and dispensers Hospitals Pharmaceutical industry Food production

Intervention area
Advocacy and intersectoral action Regulations

Policies
Guidelines and formularies Education Surveillance Infection control Diagnostic services

Target audience: Government (health systems)

Advocacy and intersectoral action
Intersectoral task force Resources to promote the implementation of interventions Indicators to monitor and evaluate the impact of resistance

Regulations
Prescription-only status International quality, safety and efficacy standards

Target audience: Government (health systems)

Policies and guidelines
National Drug Policy and Essential Drugs List (EDL)

Surveillance
Designate or develop reference microbiology laboratory facilities Drug resistance surveillance

Target audience: Patients and the general community

Health education
Appropriate use of antimicrobials Disease prevention (immunization, vector control) Hygiene

Target audience: Prescribers and dispensers

Education (undergraduate an postgraduate)
Appropriate use and containment Disease prevention and infection control Diagnosis and management

Management, guidelines and formularies

Regulation

Prescription audits / prescription limits Standard treatment guidelines and prescription limits Professional registration based on continuing

Target audience: Hospitals

Management
Infection control programmes Hospital therapeutic committees Monitor antimicrobial usage

Diagnostic laboratories
Ensure access to microbiology laboratory services Diagnostic and treatment option support

Target audience: Pharmaceutical industry

Promotional activities
Control and monitor promotion for medicines (WHO ethical criteria)

Quality
Good Manufacturing Practice (GMP) of pharmaceuticals and diagnostics

Target audience: Food production

Regulation
Prescription-only use of antimicrobials for disease control Phase out use of antimicrobials for growth promotion Monitor resistance Develop guidelines for veterinarians to reduce overuse and misuse

Guidelines

Recommendations
To Member States
National intersectoral task force on antimicrobial resistance Legislation and regulation: prescription-only use of antimicrobials Hospital therapeutics committees and infection control programmes Essential drugs concept in educational programmes

Recommendations
To WHO
Continued advocacy with Member States Support for surveillance networks Support for operational research Exploring the possibility of designating regional regulatory reference laboratories Development of a regional strategy on the prevention, control and monitoring of antimicrobial drug resistance

Some final points.

Antimicrobial resistance control is not an option, it is a must

Implementation of comprehensive, integrated strategies involving all key partners will:
Lead to control of antimicrobial resistance development Improve the quality of health services; antimicrobial resistance control as a proxy indicator for an effective essential drugs programme Health and economic incentive

Prolonged fever is a temperature above normal for three weeks or more. It may be continuous or swinging. It is not hyperthermia, which is an uncontrolled rise in temperature due to thermal overload, as in heatstroke. GF Abscess UTI here, but Carcinoma RA Many more causes exist than can be named those likeliest in general practice are listed. Generalise d Yes No No Possible No lymphaden opathy? Localised painful swelling? Frequency of micturition ? Rapid weight loss? Joint swelling? No Possible No No Possible

No

No

Yes

No

No

Possible No

Possible No

No No

Yes Possible

Possible Yes

ARBO-VIRUS = Arthopode-borne virus Penularan:

Gigitan artropoda: nyamuk, lalat extrinsic incubation period

Patokan Diagnosis Klinis

1. Demam tinggi mendadak dan kontinyu 2-7 hari 2. Nyeri Kepala, nyeri retro-bulbair, mialgia, ruam kulit, manifestasi perdarahan, dan lekopenia Manifestasi perdarahan: RL; petekie, purpura, ekimosis, epistaksis, perdarahan gusi, hematemesis dan melena 3. Renjatan hipovolemik: nadi cepat dan lemah, tekanan nadi < 20mmHg

Laboratorium
1. Trombositopenia ( < 100,000 UI) 2. Hemokonsentrasi: hematokrit > 20 vol% dari masa rekonvalesen 3. Tanda Perembesan Plasma

Derajat Penyakit DBD Gejala

Tatalaksana
Rawat Jalan

DD
DBD

Demam, 1/> nyeri kepala nyeri retro-bulbair, mialgia, antralgia, flush

Demam, gejala tidak khas, RL positif Derajat I dengan perdarahan spontan Kegagalan sirkulasi: nadi cepat, lembut, kecil, tekanan nadi < 20 mmHg, Hipotensi, kulit dingin, lembab, gelisah Renjatan berat, nadi tidak teraba, tekanan darah tidak terukur

Observasi di Puskesmas/ RS tipe C/D

DBD

II

Rawat Inap Puskesmas/ RS tipe C/D

DBD

III

Rawat Inap RS tipe C/B/A

DBD

IV

Rawat Inap RS tipe B/A

Tersangka DBD

Panas
Kedaruratan
Pre/syok, muntah kontinyu, kesadaran muntah-BAB darah, kejang
Tanpa Kedaruratan

RL + Trombosit < 150,000/ ul

Rawat

Ya

Tidak Pulang

Lapor: Dinas Kesehatan Lurah

PSN

Pencegahan DBD Pesan: KU Kontrol

Patogenesis Renjatan pada DBD

Secondary Heterologous Dengue Infection Anamnestic Antibody Virus Replication Response Virus Antibody Complex01
Complement Activation
Complement

Anaphylatoxin (C3a C5a) Vascular Permeability

> 30 % in Shock Cases 24 - 48 hrs

Histamine Level in 24-hours urine

Leakage of Plasma

Ht Na+ Fluid in the Serous Cavite

Hypovolemia

Shock
Anoxia

Acidosis

DBD Tanpa Syok

(1) Cairan Awal

RL D5 7 ml/Kg BB/Jam Monitor Tanda Vital/Kadar Ht, PP Perbaikan Tidak ada Perbaikan Ht turun Ht Naik Nadi/TD stabil PP turun Diuresis cukup Nadi naik (2) Tetesan dikurangi Tek Nadi < 20 mg Hg Vital/ 5 cc/Kb BB/jm Diuresis kurang Ht berubah (3) Tetesan Naik 3 cc/kg BB/jam 10 mg/kgBB.jam Perbaikan 15 cc/kgBB/jam Perbaikan Lanjutkan tetesan (2) Vital labil
(4) IVFD stop 24 - 48 jam Tanda vital/Ht stabil diuresis cukup Ht Naik distress Koloid (5) Ht turun Transfusi darah Perbaikan ke (2) (6)

DBD syok RL 20 cc/kgBB/jam, O2: 2-6 l/m

. Teratasi

1/2 jam

Belum teratasi
RL: 10 cc/kgBB/jam

Ht turun

Ht Naik
Koloid Dextran 40 Plasma (10 cc/kgBB/jam

Jumlah Cairan Transfusi darah seperti tanpa syok 1/2 jam

Dopamin 10 tetes/menit (8 mg/kgBB/mennit)

death

Low diet quality

poverty