PROGRAM PENGENDALIAN

RESISTENSI ANTIMIKROBA
(PPRA)
DI RUMAH SAKIT
Hari Paraton. dr. SpOGK

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

 PENDAHULUAN

1. AMR Mechanism
2. Global Problem
3. Global Action Plan
4. Situasi Nasional
5. Tugas KPRA Rumah Sakit
6. Key Performance Indicator

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTERIAN KESEHATAN
 PENDAHULUAN
selective-pressure
 PENDAHULUAN

Rp
AMR
PERILAKU
Rp Rp PROBLEM

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.
THE AMR IMPACTS
MASALAH GLOBAL

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTERIAN KESEHATAN
 MASALAH GLOBAL

2013 700.000 / tahun

WHO 2013
10.000.000/tahun
2050
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
ESBL PRODUCING
BACTERIA

PREVALENCE of ESBL in INDONESIA

70
66
surveilla
60 nce
2016
50 45-89%
presentage

40 40 WHO/
35 PPRA
30 26- ESBL
28 RSD 56%
20 RSD S
S
10 9 AMRI
0 N
2000 2005 2010 2013 2016
PENDAHULUAN
 BAGAIMANA INDONESIA

The prevalence of ESBL producing E.coli and RSUD.Dr. Soetomo 204 sample kasus
Klebsiella pneumoniae among hospitals in Jan-Juli 2010
Indonesia six hospitals 2013
N= 554
60 56,39% 56,8% 100.00%
51,69% 52,23% 90.00%
50 45,33% 80.00%
40,83% 70.00%
40 37,82% 60.00%

Persentase
34,31% 32,16% 32,7% 35,02
50.00% %(194)
30 27,94% 26,71% 40.00%
30.00%
20 20.00% 6,50%(36) 4,51%(25)
10.00%
10 0.00%
Jumlah Isolat Jumlah ESBL Jumlah PAN Jumlah
RESISTEN MRSA
0
Macam Isolat

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTRIAN KESEHATAN
 Table. Antibiotic susceptibility (n) pattern of ESBL producing E.coli

RSDS RSSA RSDM RSDK RSSD RSP TOTAL

Cefotaxime 0.17 0.00 NA 1.57 3.31 NA 0,78
Ceftriaxone 0.00 0.00 2.62 5.93 NA 0.00 1,19
Ceftazidime 0.17 0.00 12.07 4.19 8.33 0.00 3,83
Cefepime 0.34 42.06 26.21 9.42 25.62 0.00 12,78
Ciprofloxasin 16.10 29.37 10.00 18.32 7.50 10.42 15,21
Amikacin 97.95 95.24 82.99 96.34 73.33 98.96 92,4
Gentamycin 61.43 69.05 62.15 10.99 56.30 63.54 55,12
Fosfomycin 92.86 100.00 NA 78.57 82.89 NA 90,85
Piperacillin-
49.57 76.19 NA 76.44 65.81 66.67 60,4
tazobactam
Cefoperazone-
53.85 NA 83.33 72.73 57.98 15.63 57,08
sulbactam
Meropenem 99.83 98.41 98.96 95.29 94.96 100.00 98,51
Levofloxacin 20.14 29.37 9.00 21.48 15.38 10.42 17,66
Tigecyclin 78.08 99.21 97.92 99.48 40.63 100.00 94,67

Data surveillance PPRA RSDS-Balitbangkes-WHO 2013

14
MASALAH GLOBAL

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTERIAN KESEHATAN
PEMICU RESISTENSI
SELECTIVE
PRESSURE

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

Tidak ada
indikasi 55 81
profilaksis

AMRIN STUDY : 2002-2005

16 16
Proble Pertanian/
Peternakan
ms /perikanan
Growth
Map promoto
r
Cegah
infeksi
Regula
si

Food Kurikul
Knowled Residu AB Insent um
ge if
(+)
Training
R AB / R /Semina
OTC/Apat self AMR AB/ Knowle r
ek medikas dge
i RS DR Worksh
op

Regulasi Mikro ASP KM/K

klinik FT

Farma TOP
si MGT
klinik
PPI Klinis
i
 HEALTH RESOURCES IN INDONESIA 2016

Profesion total Facilities total

Hospital 2.415
Specialist 32.280
Health center 9.600
GP 116.900 Drug store 24.000
Dentist 31.360 Medical Faculty 73
Dentistry Faculty 27
Midwife 400.000
Pharmaceutical 127
Nurse 288.000 Faculty
Midwife Academy 720
Pharmacist 54.900. Nurse academy 300 18
KPRA Training Pathway 2016
• standardization of
Hospital AMR Program
ARCC of MoH training
• Training of the Trainer
• research: AMR,
Antibiotic use, sepsis,
AMR related infection
34 National and cost
Provincials Referral • National AB - AMR
Hospitals Surveillance

110 Regional Private and District Primary

Referral Hospitals Hospitals Health Care

community education
 STRATEGI UTAMA

CEGAH
SELECTIVE CEGAH KENDALI

PRESSURE TRANSMISI LINGKUNGAN

ANTIBIOTIK KEWASPADAAN
DEKOLONISASI
BIJAK UNIVERSAL

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTERIAN KESEHATAN
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
 KPRA – RS
PERMENKES no 8/2015

PERMENKES no 8/2015; pasal 9 tugas Komite

PRA, membantu kepala/direktur rumah rakit:
1. menetapkan kebijakan pengendalian resistensi
antimikroba
2. menetapkan kebijakan umum dan panduan
penggunaan antibiotik di rumah sakit
3. pelaksanaan program pengendalian resistensi
antimikroba
KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA
KEMENTERIAN KESEHATAN
 KPRA – RS
PERMENKES no 8/2015

4. mengawasi dan mengevaluasi pelaksanaan

program pengendalian resistensi antimikoba.
5. menyelenggarakan forum kajian kasus
pengelolaan penyakit infeksi terintegrasi
6. melakukan surveilans pola penggunaan
antibiotik
7. melakukan surveilans pola mikroba penyebab
infeksi dan kepekaannya terhadap antibiotik

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTRIAN KESEHATAN
 KPRA – RS
PERMENKES no 8/2015

8. menyebar luaskan serta meningkatkan pemahaman

dan kesadaran tentang prinsip pengendalian resistensi
antimikroba, penggunaan antibiotik secara bijak, dan
ketaatan terhadap pencegahan pengendalian infeksi
melalui kegiatan pendidikan dan pelatihan
9. mengembangkan penelitian di bidang pengendalian
resistensi antimikroba
10. melaporkan kegiatan program pengendalian resistensi
antimikroba kepada Direktur/Kepala rumah sakit.

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTRIAN KESEHATAN
 KPRA – RS
PERMENKES no 8/2015

Pasal 11: KPI

1. penggunaan antibiotik kualitas / kuantitas
2. pola kepekaan antibiotik dan pola resistensi
antimikroba
3. angka kejadian infeksi AMR
4. mutu penanganan kasus infeksi secara
multidisiplin

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTERIAN KESEHATAN
 KPRA adalah Forum
Koordinasi AKSELERASI

PPI FARMASI

KPRA

MIKROBI
KFT OLOGI
KLINIK

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTRIAN KESEHATAN
 LANGKAH PENDEKATAN
PPRA-RS

FULL
INITIAL PILOT IMPLEME SUSTAIN
NT

• inform direksi • Tim /SK. • Direktur • Review PPK

RS Direktur memperluas • Peta Pola Bakteri 6
• sosialisasi • Guideline/PPK jangkauan bulan
• pilih Dept/SMF • Sosialisasi • tetapkan • surveillance AMR
untuk Pilot • study Retro dan Dept/SMF dan AMU
Prospektif • Feed back AMR dan
• Analisis-  FB AMU

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTERIAN KESEHATAN
LANGKAH KEGIATAN PPRA

TIM PPRA REN -GRAM

/ KPRA IMPEMENTASI OUTCOME
KERJA

• SK Direktur • anggaran • pelatihan utk • Prevalence

• keanggotaan • bertahap staff/PPDS-I AMR
(MK, FK, KFT,  pilot • surveilance • AMU bijak
PPI, Klinisi) berkembang, AMR/AMU • Mortalitas/m
• Job Des. berkesinambu • Pola Bakteri orbidit
ngan • monev • Kajian Kasus
• up-date PPK

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTRIAN KESEHATAN
 Profil Konsumsi Antibiotik Total (DDD/100 patient days)
IRNA Medik-SMF Peny.Dalam

Metronidazol 37.95

Meropenem 11.61

Lefofloxacin 5.80

Ciprofloxacin 29.11

Ceftriaxone 23.66

Ceftazidime 0.89

Cefotaxime 5.25

Cefo-sulbactam 1.00

Cefixime 0.67

Ampicillin 29.46

Amoxicillin 3.35

Amoxiclav 58.93

Amikacin 1.12

0.00 10.00 20.00 30.00 40.00 50.00 60.00

30
 Profil Kualitas Penggunaan Antibiotik Total (kriteria Gyssens)
IRNA Medik-SMF Peny.Dalam

40.00
37.10

35.00

30.00
25.81

25.00

20.00
16.13

15.00

9.68
10.00
6.45
4.84
5.00

0.00
VI V IVa IIIa IIIb 0
% RATIO 16.13 25.81 6.45 4.84 9.68 37.10
31
 Survellans Penggunaan Antibiotik

IRNA Anak
60 54.35 IRNA Medik-SMF Peny.Dalam
50 37.10
40.00
40
30.00 25.81
30 21.74
20.00 16.13
20 9.68
10.87 6.45
6.52 10.00 4.84
10 2.17 2.17 2.17
0.00
0 VI V IVa IIIa IIIb 0
VI V IVa IIIa IIIb IIb 0
% RATIO 16.13 25.81 6.45 4.84 9.68 37.10
% RATIO 6.52 10.87 2.17 21.74 2.17 2.17 54.35

Peny. Paru IRNA Bedah

59.52
50 60
50
50
40 35
40 33.33
30
30
20 13.75 20
7.14
10 10
1.25
0 0
V Iva IIIb 0 VI V 0
% RATIO 35 13.75 1.25 50 % RATIO 7.14 59.52 33.33
32
OUTCOME 5 (3) TAHUN KEDEPAN

Ketaatan terhadap PPK antibiotik 75%

Penggunaan antibiotik 50%

Surveillance nasional secara regular 1x

Angka kematian sepsis 25%

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTRIAN KESEHATAN
TERIMA KASIH

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTERIAN KESEHATAN