Pengendalian Resistensi Anti Mikroba di Rumah Sakit

PROGRAM PENGENDALIAN
RESISTENSI ANTIMIKROBA DI RUMAH
SAKIT
HARI PARATON. dr. SpOGK
KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA
AMR & RUMAH SAKIT?
• AMR banyak di Rumah sakit (ICU,
ICCU, NICU, PICU, Int. Care, Rawat
inap. Infeksi)
• Antibiotik sistemik banyak
digunakan di RS
• HAI  prevalensi meningkat
• Staff medis RS perlu pemahaman
• 50-80% Antibiotik digunakan tidak
tepat.
PENGGUNAAN
ANTIBIOTIK DI RUMAH
SAKIT
Kategori
Hasil
Sby Semg
(%)
(%)
Tidak ada
indikasi
terapi
76
53
Tidak ada
indikasi
profilaksis
55
81
AMRIN STUDY : 2002-2005
4
4
THE PROBLEM
ANTIBIOTIC
USE
HAI
•
•
•
•
•
AMR
more difficult to treat
more procedures
high cost
ICU use
failure  morbidity and mortality
•
•
•
•
Blood stream
Pneumonia
UTI
SSI
ESBL PRODUCING
BACTERIA
PREVALENCE of ESBL in INDONESIA
70
66
60
presentage
50
40
35
30
28
20
10
40
RSDS
9
AMRI
N
2000
2005
0
2010
RSDS
2013
WHO/
PPRA
2656%
2016
surveilla
nce 2016
45-89%
ESBL
Table. Antibiotic susceptibility (n) pattern of ESBL producing E.coli
Cefotaxime
Ceftriaxone
Ceftazidime
Cefepime
Ciprofloxasin
Amikacin
Gentamycin
Fosfomycin
Piperacillintazobactam
Cefoperazonesulbactam
Meropenem
Levofloxacin
Tigecyclin
RSDS
0.17
0.00
0.17
0.34
16.10
97.95
61.43
92.86
RSSA
0.00
0.00
0.00
42.06
29.37
95.24
69.05
100.00
RSDM
NA
2.62
12.07
26.21
10.00
82.99
62.15
NA
RSDK
1.57
5.93
4.19
9.42
18.32
96.34
10.99
78.57
RSSD
3.31
NA
8.33
25.62
7.50
73.33
56.30
82.89
RSP
NA
0.00
0.00
0.00
10.42
98.96
63.54
NA
TOTAL
0,78
1,19
3,83
12,78
15,21
92,4
55,12
90,85
49.57
76.19
NA
76.44
65.81
66.67
60,4
53.85
NA
83.33
72.73
57.98
15.63
57,08
99.83
20.14
78.08
98.41
29.37
99.21
98.96
9.00
97.92
95.29
21.48
99.48
94.96
15.38
40.63
100.00
10.42
100.00
98,51
17,66
94,67
Data surveillance PPRA RSDS-Balitbangkes-WHO 2013
7
GLOBAL AMR
KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN
PENDAHULUAN
When I was asked to chair the Review on
Antimicrobial Resistance (AMR), I was
told that AMR was one of the biggest
health threats that mankind faces now
and in the coming decades. My initial
response was to ask, ‘Why should an
economist lead this? Why not a health
economist?’ The answer was that many of
the urgent problems are economic, so
we need an economist, especially one versed
in macro-economic issues and the world
economy, to create the solutions.
MASALAH GLOBAL
KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN
THE AMR IMPACTS
MASALAH GLOBAL
WHO 2013
2013
700.000 / tahun
2050
10.000.000/tahun
USD. 100 TRILLIUN
(Jim O Neill 2015)
KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN
WHO; Global Action Plan
1. Improve awareness and understanding of antimicrobial resistance
through effective communication, education and training
2. Strengthen the knowledge and evidence base through surveillance a
nd research.
3. Reduce the incidence of infection through effective sanitation, hygiene
and infection prevention measures.
4. Optimize the use of antimicrobial medicines in human and ani
mal health.
5. Develop the economic case for sustainable investment that takes acco
unt of
the needs of all countries, and increase investment in new medicines,
diagnostic tools, vaccines and other interventions.
KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN
Proble
ms
Map
Pertanian/
Peternakan
/perikanan
Growth
promotor
Food
Residu AB
(+)
Knowledg
e
OTC/Apate
k
Regulasi
Cegah
infeksi
R AB /
self
medikasi
AMR
RS
Regulasi
Kurikulu
m
Insenti
f
R AB/
DR
Knowled
ge
ASP
Mikro
klinik
KM/K
FT
Farmasi
klinik
TOP
MGT
PPI
Klinisi
Training/
Seminar
Worksho
p
PERLUNYA HIGH QALITY CARE
KASUS
OPERASI
SEMBUH
IDO
•
•
•
•
•
DELAYED
COST
TENAGA
KENYAMANAN
NEGATIVE
PROMOTION
SEMBUH
MENINGGAL
CACAT
HEALTH RESOURCES IN INDONESIA 2016
Profesion total
Specialist 32.280
GP
116.900
Dentist
31.360
Midwife
400.000
Nurse
288.000
Pharmacist 54.900.
Facilities
total
Hospital
2.415
Health center
9.600
Drug store
24.000
Medical Faculty
73
Dentistry Faculty
27
Pharmaceutical
127
Faculty
Midwife Academy 720
Nurse academy
300
18
REGULASI SEBAGAI
LANDASAN HUKUM
KPRA – RS
PERMENKES no 8/2015
pasal 6
Setiap rumah sakit harus melaksanakan
Program Pengendalian Resistensi Antimikroba
secara optimal.
pasal 7
susunan organisasi Komite / Tim Pelaksana
Program Pengendalian Resistensi Antimikroba
pasal 8
Keanggotaan tim pelaksana Program
Pengendalian Resistensi Antimikroba rumah
sakit
KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA KEMENTERIAN KESEHATAN
PARADIGMA MENGATASI BAKTERI RESISTEN
Mengguna
kan normal
flora
Save
Normal
Flora
ASP,
Limitasi
Antiseptik
Host
defence
/Immunitas
Temukan
ANTIBIOTIK
baru
Cegah
Transmisi
AMR
Cegah
Resistensi
Pro-Pre
biotik
Lama, Cost
tinggi, Sulit
PPI/Universal
precaution
Antibiotik
Bijak
Cuci Tangan
ASP
ANTIBIOTIK TERAPI DAN PROFILAKSIS
DALAM RANGKA PENGENDALIAN
RESISTENSI ANTIBAKTERI DI RUMAH SAKIT
HARI PARATON. dr. SpOGK
KOMITE PENGENDALIAN RESISTENSI
ANTIMIKROBA
•
•
•
•
Anak 1,4 tahun, operasi Tetralogy Fallot hari 16.
Temp/ 37-39C, PCT > 5, lekosit 23.000.
Pus luka op. Pathogen: Acinotobacter baumannii
Resistance to Cephalosphorine, Meropenem, Amikacin,
Fosfomycin.
ANTIBAKTERI
TERAPI
PRINSIP PENANGANAN
PASIEN INFEKSI
Bakter
i
antibiot
ikempiri
k
mikrobiolo
gi
infeksi
NonBakter
i
sourc
e
contr
ol
antibiot
ik
definitif
• Monitori
ng
• follow up
• deeskala
si
• stop
25
LANGKAH PERESEPAN
ANTIBAKTERI
1. Apakah pasien sakit infeksi ?
suhu tubuh > 38C, Nadi >90
2. Apakah infeksi bakteri
Lekosit>11.000, CRP(+), PCT
(+)
3. Apakah ada penyebab /
sumber
infeksi?
kateter, drain, tampon, abces
• Demam Berdarah ?
• Stroke ?
• Asthma attack ?
DOSIS DAN WAKTU PEMBERIAN ANTIBIOTIK
PEMICU MUTASI BAKTERI  RESISTEN
MPC
Window of
Selection
MIC
MIC: Minimal inhibitotr concentration MPC: mutant prevention
concentratration)
ANTIBAKTERI
PROFILAKSIS
TERAPI
PROFILAKSIS
1. Antibakteri, yang
digunakan untuk mencegah
komplikasi infeksi pada
tindakan operasi.
2. diberikan sebelum operasi,
ulangan saat operasi atau
setelah operasi
3. batasan waktu: tidak
melebihi 24 jam
INDIKASI PROFILAKSIS
•
•
•
•
•
GOLONGAN OPERASI
bersih
bersih kontaminasi
kontaminasi
kotor
kolonisasi
Antibiotika profilaksis
Profilaksis Dosis Tunggal v/s Multipel
Fakta
laporan
Tidak ada
perbedaa
n
signifikan
Single-dose versus multiple-dose antibiotic prophylaxis for
the surgical treatment of closed fractures .
Slobogean.et.al. Acta Orthopaedica 2010; 81 (2): 256–262
Results: A total of 540 patients were recruited; (females73.7% of total ). The performed surgical
procedures were 547. The rate of wound infection was 10.9%. Multivariable logistic analysis
showed that; ASA score > 3; (p= <0.001), wound class (p= 0.001), and laparoscopic surgical
technique; (p= 0.002) were significantly associated with prevalence of wound infection. Surgical
prophylaxis was unnecessarily given to 311 (97.5%) of 319 patients for whom it was not
recommended. Prophylaxis was recommended for 221 patients; of them 218 (98.6 %) were given
preoperative dose in the operating rooms. Evaluation of prescriptions for those patients showed
that; spectrum of antibiotic was adequate for 160 (73.4%) patients, 143 (65.6%) were given
accurate doses, only 4 (1.8%) had the first preoperative dose/s in proper time window, and for
186 (85.3%) of them prophylaxis was extended post-operatively. Only 36 (6.7%) prescriptions
were found to be complying with the stated criteria.
Conclusion: The
rate of wound infection was high and prophylactic
antibiotics were irrationally used. Multiple interventions are
needed to correct the situation.
cara pemberian
AB PROFILAKSIS
• Antibakteri
– Cefazolin 2 g
– Cefuroxime 1,5 g
•
•
•
•
•
•
dikamar operasi
i.v/drip dalam 100 ml NS
30 menit sebelum insisi
dalam 15 menit
tanpa skin test
tidak perlu pemberian AB oral
pasca operasi
SIGN
2015
Prosedure
Antibiotik
Evidence
Level
Odd.Rt
HR
1
0.41
R
1
0.17
Tonsilectomy
NR
1
Luka pada wajah
NR
1
Partus normal +
episiotomi
NR
1
Strumecomy
NR
1
Ca Mammae
R
1
Appendectomy
HR
1
Colorectal surgery
HR
1
Hernia
NR
1
TUR prostate
HR
1
Arthroplasty
HR
1
Pemasangan kateter
NR
1
Sectio Cesarea
Histerektomi TAH / TVH
0.58
3 - TAKE HOME MESSAGE
1. RS melaksanakan Permenkes no.8/2015
2. RS memiliki kebijakan, pedoman dan PPK
penggunaan antibiotik terapi dan profilaksis
3. penggunaan antibiotik bijak
 menekan jumlah dan jenis penggunaan antibiotik
 menekan angka komplikasi, resistensi, kesakitan
dan kematian
 menekan pembeayaan pelayanan pasien
4. Perlu adanya monev dan surveillance
HARAPAN BERSAMA
PREVALENCE of ESBL in INDONESIA
70
surveillan
ce 2016
45-89%
60
60
HARAPAN
KITA
BERSAMA
presentage
50
40
35
30
40
RSDS
RSDS
20
AMRI
N
9
0
2000
ESBL
30
28
20
10
40
2005
2010
2013
2016
2017
2018
2019