HARI

PARATON
KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA
KEMENTERIAN KESEHATAN R.I

MENGAPA PERLU ANTIBIOTIK PROFILAKSIS
dokter takut kalauterjadi IDO
•  beban perasaan dokter
•  reputasi dokter
•  pasien menderita
•  beban biaya

dokter ikut pengalaman yang lalu

•  operasi = profilaksis
•  pelajaran saat PPDS I
•  ikut seniornya

•  Pasien meminta An8io8k

STANDARISASI AB PROFILAKSIS

?
PREVALENSI TERJADI IDO
 kolonisasi

An8bio8ka profilaksis
Definisi Antibiotik profilaksis:
Antibiotik yang diberikan sebelum-saat-setelah operasi
pada kasus yang secara klinis tidak terdapat tanda infeksi.
Tujuannya untuk mencegah terjadinya ILO / SSI / IDO dan
mencegah kolonisasi

Golongan operasi
•  Bersih
•  Bersih terkontaminasi
PROFILAKSIS DOSIS TUNGGAL V/S MULTIPEL

Fakta Tidak ada
laporan perbedaan
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.
The rate of wound infection was high and
Conclusion:
prophylactic antibiotics were irrationally used. Multiple
interventions are needed to correct the situation.
Results: Perioperative antibiotic prophylaxis was appropriate in 18.1% of cases. The
multivariate logistic regression analysis showed that patients with hypoalbuminemia, with a clinical
infection, with a wound clean were more likely to receive an appropriate antibiotic prophylaxis.
Compared with patients with an American Society of Anesthesiologists (ASA) score 4, those with a
score of 2 were correlated with a 64% reduction in the odds of having an appropriate prophylaxis. The
appropriateness of the timing of prophylactic antibiotic administration was observed in 53.4% of the
procedures. Multivariate logistic regression model showed that such appropriateness was more
frequent in older patients, in those admitted in general surgery wards, in those not having been
underwent an endoscopic surgery, in those with a higher length of surgery, and in patients with ASA
The most common
score 1 when a score 4 was chosen as the reference category.
antibiotics used inappropriately were ceftazidime, sultamicillin,
levofloxacin, and teicoplanin.
Conclusions: Educational interventions are needed to improve
perioperative appropriate antibiotic prophylaxis.
 Profil pemberian antibiotik
RS Dr.Soetomo & Dr. Kariadi (AMRIN study 2005)

Hasil
kategori
Sby (%) Semg (%)
Tidak ada indikasi
terapi
76 53

Tidak ada indikasi

profilaksis
55 81
KEBIJAKAN RUMAH SAKIT

•  An@bio@k profilaksis diusulkan oleh Dep/SMF

ditetapkan oleh KFT dan Direktur Rumah sakit
•  An@bio@k profilaksis @dak digunakan untuk
keperluan terapi
•  Dilakukan monitoring evaluasi se@ap 2-3 tahun.
Persiapan pasien operasi
 SCREENING FOR ESBL COLONIZATION

Recommendation
The panel decided not to formulate a recommendation due to the lack of
evidence.

Rationale for the recommendation

The literature search did not identify any relevant studies comparing the
tailored modification of SAP for the prevention of SSI in areas with a high
prevalence of extended spectrum beta-lactamase (ESBL)-producing
Enterobacteriacae (including patients with rectal colonization of ESBL) to no
modification of standard antibiotic prophylaxis. Furthermore, no studies
comparing routine screening for ESBL (irrespective of ESBL prevalence prior
to surgery) with no screening that could inform a recommendation for this
question were identified.
(WHO 2015)
 IDO dan kadar Glukosa

8 Glucose control (200 mg/dl

6.7%

Deep Infec8on Rate, %

7
6 P=0.002
5
4
3
2.5%
1.3% 1.6%
2
1
0
100–150 150–200 200–250 250–300
Day 1 Blood Glucose (mg/dL)
Zerr KJ et al. Glucose control lowers the risk of wound infec7on in diabe7cs a9er open heart opera7ons, page 360.
Reprinted from The Annals of Thoracic Surgeons, Vol. 63.
 Elec@ve •  200 CRS pa@ents
Surgical –  Control: Rou@ne intraopera@ve
thermal care
Procedures (mean temperature 34.7°C)
Periopera@ve –  Treatment: Ac@ve warming
Normothermia (mean temperature 36.6°C)

•  Incidence of SSI
–  Control 19% (18/96)
Warm Pa8ent Strategies:
• Start with warm room
• Use Bair Hugger
–  Treatment 6% (6/104);
• Cool room for procedure P=0.009 cold pa@ents
• Use 40o irriga@on
• Warm room on closing had 3x infec@on
GOAL : >36oC (98.6oF) rate

Kurz A et al. N Engl J Med. 1996;334:1209–1215.

 Elec@ve
Surgical •  500 CRS pa@ents
Procedures –  80% or 30% inspired oxygen during
opera@on and for 2 hours post surgery
Supplemental
–  All pa@ents received prophylac@c
Oxygen
an@bio@cs

•  Results
–  Arterial and subcutaneous PO higher in 2
80% oxygen group
–  Lower incidence of SSIs with higher
Oxygen Strategy: supplemental oxygen (5.2% vs 11.2%;
• Supplemental O2 P=0.01)
for 2hrs in RR
low O2 2x infec@on rate

Greif et al. N Engl J Med. 2000;342:161–167.


Pencegahan Menjelang Operasi
infeksi
terkendali •  Tidak gelisah
•  Tidur cukup
–  R/ Sleep inducer
•  Pasien mandi bersih dengan sabun
•  sabun chlorhexidine bagi bedah
thorax / orthopedi + MRSA (+)
 Elec@ve
Surgical
Procedures
Hair Clipping hair just before case is best

Removal Hair Removal Infection Rate

Method
sore / kerok/shaving 5.2 - 8.8%
pagi / kerok 6.4 - 10%
sore / cukur 4 - 7.5%
pagi / cukur 1.8 - 3.2%

Alexander JW, et al. Arch Surg 1983; 118:347-352

ANTIBIOTIK PROFILAKSIS

•  Cephalosporin gen I –II

•  Cephazolin (2 gr)
•  Cefuroxime 1.5 gr)
•  Pada kasus alergi Cefalosporin
•  Ampisilin sulbaktam (1 gr)
•  Amoksisilin as. Klavulanat (1 gr)
•  Gentamisin (5-8 mg/kg BB)
•  Pada kasus bedah digestif
•  Kombinasi Metronidazole ( 500 mg)
•  Pada kasus bedah saraf
•  Ceftriaxon (1 - 2 gr)

19
 Timing Insisi
6
5

4
SSI (%)

3
2

1
0
2 0 2 4 6 8 10

hours
Harbarth et al, Circula@on 2000
Classen et al. N Engl J Med 1992
 CARA PEMBERIAN
AB PROFILAKSIS

30-60 menit sebelum insisi

•  Intravenous – driP
–  dilarutkan dalam 100 ml normal saline
•  Lama pemberian 15-30 menit
•  Dosis tunggalà max 24 jam
•  Tidak perlu “skin test” ?
•  Ditentukan dokter pembedah
•  diberikan oleh staf anestesi


 SAAT OPERASI
ANTIBIOTIK PROFILAKSIS

•  An@bio@k boleh diulang

–  perdarahan >1000 ml
–  Lama op >2-3 jam
–  Jenis dan dosis yang sama
–  an@bio@k tambahan bisa diberikan apabila
terjadi komplikasi atau diagnosis tambahan à
Abses
 ANAPHILAKSIS

•  Angka kejadian 0.0025 % (25/1.000.000) pada

pemberian gol. Penisilin
–  36 % diketahui allergy terhadap penisilin
–  64 % @dak ada riwayat allergy
•  (Clinical Medicine & Research Volume 8, Number 2:
80-81, 2010 Marshfield Clinic. Clinmedres.org)
 ANAPHILAKSIS

•  Reaksi silang anaphilaksis antara gol. Penisilin terhadap

cephalosphorin à 10 %
•  Pasien dengan riwayat setelah mendapat gol. Penisilin
à berisiko terjadi pada pemberian beta lactam (C)
–  Anaphylaxis
–  laryngeal oedema
–  Bronchospasm
–  Hypotension
–  local swelling
–  Urticaria , pruritic rash
(SIGN. antibiotic prophylaxis in Surgery . 2008.)
 PENELITIAN
PENGGUNAAN ANTIBIOTIKA PROFILAKSIS
di Dep/SMF. Obstetri Ginekologi RSUD. Dr. Soetomo. (AMRIN 2003- 2004)

Operasi Angka ILO

Histerektomi Sub Total 0/46

Histerektomi Total 1/277

 Kasus & Prosedure
An8bio8k
Evidence
Level
Odd.Rt

an@bio@k Sec@o Cesarea HR 1 0.41

profilaksis Histerektomi TAH / TVH 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 0.58
Colorectal surgery HR 1
Hernia NR 1
TUR prostate HR 1
Arthroplasty HR 1
Pemasangan kateter NR 1
HINDARI IDO GUNAKAN ANTIBIOTIK
PROFILAKSIS SECARA BENAR.