PROGRAM PENGENDALIAN

RESISTENSI ANTIMIKROBA
DI RUMAH SAKIT
HARI PARATON. dr. SpOGK

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

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
AMR: GLOBAL PROBLEMS
THE AMR IMPACTS
 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
 AMR: Global problem, Mortality and
Economic impact

§ EROPA THAILAND USA USA

UNION
• Population 70 M
• Population 300 M • Population 250 M
-Populatin 500 M • >38.000 death/
• >23.000 death/ • >135.000 death/
-25.000 death/ yrs
yrs yrs
year • 3.2 Mextra ALOS • 2 Mextra ALOS • Cost Rp. 56. T
-2,5 Mextra ALOS • Cost US$ 1.3 B • Cost US$ 20 B
-Cost € 1.5 / yrs

WHO, 2007 9
 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

12
ESBL PRODUCING
BACTERIA

PREVALENCE of ESBL in INDONESIA

70 66
survailans
60 2016
45-89%
50
40
presentage

40 35
28 WHO/ ESBL
30 PPRA
RSDS 26-56%
20 RSDS
9
10 AMRIN
0
2000 2005 2010 2013 2016
 THE PROBLEM
ANTIBIOTIC
USE

• Blood stream
• Pneumonia
HAI AMR • UTI
• SSI

• more difficult to treat

• more procedures
• high cost
• ICU use
• failure  morbidity and mortality
PEMICU RESISTENSI
SELECTIVE PRESSURE

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

Tidak ada
indikasi 55 81
profilaksis

AMRIN STUDY : 2002-2005

15 15
THEORY SELECTIVE PRESSURE

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTRIAN KESEHATAN
 LANGKAH STRATEGIK

5 Strategic
global problem objective
PPRA

peningkatan turunnya
Prevalensi AMR prevalensi AMR
 WHO:
Global Action Plan

1. Improve awareness and understanding of antimicrobial resis-

tance through effective communication, education and training
2. Strengthen the knowledge and evidence base through surveillan-
ce and research.
3. Reduce the incidence of infection through effective sanitation, hygi-
ene and infection prevention measures.
4. Optimize the use of antimicrobial medicines in human and
animal health.
5. Develop the economic case for sustainable investment that takes
account ofthe needs of all countries, and increase investment in
new medicines, diagnostic tools, vaccines and other interventions.

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

Harry Parathon 19
KEMENTERIAN KESEHATAN
PRUDENT USE OF ANTIBIOTIC

Prudent use of antibiotics has 3 components,

• rational use,
• adherence to local guidelines and policies,
• avoidance or reversal of upward demographic trends in
antibiotic resistance (Phillips, CID. 2001)

The prudent use of antimicrobials as usage of antimicrobials

which maximizes therapeutic effect and minimizes the
development of antimicrobial resistance (WHO, 2008)
 BAKTERI RESISTEN

Rational use

Missuse • Efflux
• Degradation enz
Overuse
• Altering enz
• Biofilm
Underuse
 WHO priority pathogens list for R&D of
new antibiotics ( WHO, 27 February 2017)
• Priority 1: CRITICAL
– Acinetobacter baumannii, carbapenem-resistant
– Pseudomonas aeruginosa, carbapenem-resistant
– Enterobacteriaceae, carbapenem-resistant, ESBL-producing
• Priority 2: HIGH
– Enterococcus faecium, vancomycin-resistant
– Staphylococcus aureus, methicillin-resistant, vancomycin-intermediate and
resistant
– Helicobacter pylori, clarithromycin-resistant
– Campylobacter spp., fluoroquinolone-resistant
– Salmonellae, fluoroquinolone-resistant
– Neisseria gonorrhoeae, cephalosporin-resistant, fluoroquinolone-resistant
• Priority 3: MEDIUM
– Streptococcus pneumoniae, penicillin-non-susceptible
– Haemophilus influenzae, ampicillin-resistant
– Shigella spp., fluoroquinolone-resistant
 Pertanian/
Peternakan
Problems /perikanan
Map Growth Cegah Regulasi
promotor infeksi

Food Kurikulum
Knowledge Residu AB Insentif
(+)

Training/
R AB / AMR R AB/ Know- Seminar
OTC/Apotek self DR ledge
medikasi RS Workshop

Regulasi
Mikro ASP
KM/KFT
klinik

Farmasi TOP
klinik MGT
PPI Klinisi
 AMR MENJADI BEBAN
RUMAH SAKIT RUJUKAN

RUMAH RUMAH SAKIT RUMAH

SAKIT SAKIT
 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 25
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
PPRA = Kerja sama multi disiplin

KFT
PPI
MIKRO
KEPERA KLINIK
WATAN
FARMASI PRA
RUMAH
SAKIT
 KPRA adalah Forum
Koordinasi AKSELERASI

PPI FARMASI

KEPERA KLINISI
KPRA
WATAN DOKTER
MIKROBI
KFT OLOGI
KLINIK

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTRIAN KESEHATAN
 LANGKAH PRIORITAS
LANGKAH PRIORITAS
1. PPRA Diperlukan di setiap Rumah sakit, untuk
mengendalikan meningkatnya prevalensi AMR
2. KPRA/Tim PRA dibentuk berdasarkan SK Direktur
3. Anggota: Klinisi dokter, Mikrobiologi klinik,
Keperawatan, Farmasi klinik, PPI, KFT, dll
4. Perencanaan program dan implementasi, surveillance
5. Kerja..Kerja...Kerja
Strategi Utama Penurunan Prevalensi
Bakteri Resisten

PPI, HS,
IMMUNISASI

SURVEILLANCE ANTIBIOTIK
DAN RISET BIJAK

KESADARAN
DAN
AMR INOVASI AB
BARU, RAPID
KESEPAHAMAN
 TEST
 Kecepatan
penemuan
antibiotik

Timbulnya
resistensi
kuman

- Post antibiotic era

- Kembali ke zaman
pra antibiotik
- Peningkatan kematian
karena penyakit infeksi

Bagan Waktu
Spekulatif
32
HARAPAN BERSAMA

PREVALENCE of ESBL in INDONESIA

70
surveillance 66
2016
60 45-89% HARAPAN
KITA
50 BERSAMA
presentage

40 40 40
35 RSDS
30 30 ESBL
28
20 RSDS 20
10 9
AMRIN
0
2000 2005 2010 2013 2016 2017 2018 2019
TERIMA KASIH

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTERIAN KESEHATAN