Curiculum Vitae (CV)

• M.D, Franciscus Ginting

(Faculty of Medicine Universitas Sumatera Utara, Indonesia)
• Franciscus Ginting is a Internal Medicine, works at the Departement of Internal Medicine of Adam Malik Hospital
/Faculty of Medicine Universitas Sumatera Utara , Medan, Indonesia. After acquiring his medical degree (M.D), he
completed postgraduate degree (Magister Kesehatan) in field Internal medicine from Universitas Sumatera Utara
& his clinical training in Internal medicine (SpPD) at Adam Malik Hospital/Faculty of Medicine Univeristas Sumatera
Utara .
• Since 2017, he has been involved as a head of Antimicrobial stewardship programme (ASP) of at Adam Malik
Hospital a tertiary hospital Medan . Now he is become a PhD student at the Academic Medical Center of the
University of Amsterdam under SPIN-KNAW project, entitled: “Novel strategies and tools for antimicrobial
resistance surveillance”. His PhD research focuses on Validation and application of Lot Quality Assurance Sampling
(LQAS) to estimate prevalence of antimicrobial drug resistance.
Appropriate Antimicrobial Treatment for
Complicated Skin & Soft Tissue Infection
(CSSTI)
By : dr. Franciscus Ginting, Sp.PD – KPTI
 Introduction
• Incidence of SSTI
• 2005 – 2010 more than 3 millions comes to ER (increase from preceding 15 years)
• Septic cSSTI → 4,3% - 10,5%
• United States
❑ hospitalised SSTI : 58,6 % superficial infection (Uncomplicated SSTI) and 41,4 % deeper
infection (complicated ssti)
❑ 2% – 5,8 % hospitalised SSTI admitted to the ICU
❑ 0,4 % SSTI admitted to the ICU with 60 % are necrotizing fasciitis (fatal infection)
• Asian
❑ limited data
❑ China in 2008 – 2013 (Xiaoman study) : 527 cases cSSTI 61,4 % are gram + - ve and
46,20 % are gram - ve
❑ Taiwan 53 - 83 % SSTI are caused by MRSA
• Indonesia :
❑ 2010 : Cipto Mangunkusumo Hospital :
o cSSTI >10% of cases.
o bacteria 74,3% gram - ve bacteria ( 19,5% pseudomonas sp) .
❑ 2016: H. Adam Malik Hospital ,Medan SSTI is the 3rd common cause of sepsis (12,8%)
after Pneumonia (56,5%) and UTI (16,5%)
Classification SSTI
SSTI

Complicated
Uncomplicated • Infection extend to subcutaneous tissue, fascia or
• infections are superficial muscle
• Often self-limiting • Life treatening
• Can usually be treated • Required complex treatment with combined antibiotic
successfully by incision and and need surgical intervention
drainage alone or in combination
with oral antibiotics 1. Surgical site infection 2.Ulcus decubitum
3. Trauma 4. Bite wound infection
1. Impetigo 5. Ulkus diabeticum 6. Fournier Ganggren
2. Abses cutaneus 7. Infection cause necrotizing :
3. Furunkel & Carbuncle • Pyomyisitis
4. Erisepelas • Necrotizing Fascitis
• Clostridial necrotizing
5. Selulitis(mild)
Pathogenesis
Diagnosis of cSSTI
Diagnostic
Culture
• Indicated for the patient who presents exudates or abscess and requires operative incision
and drainage after debridement and cleansing of necrotic tissues.
• Traditional culture : delay the result
• Superficial techniques: commensal microba
• The sensitivity of blood cultures, especially in patients with cellulitis → low.
• Tissue biopsies after deep debridement advancing margin of the lesion → specimen of
choice
• Pus on a surface swab → inadequate and does not represent the disease process.
Imaging
• Plain radiography: gas in the soft tissue, osteomyelitis → low accuracy
• US :guidance diagnostic ( aspiration),differentiate cellulites/abscess
• CT: guide fluid aspiration
• MRI:
▪ differentiates cellulitis/abscess,
▪ Detecting necrosis, inflammatory edema/muscular/fascia involvement
MANAGEMENT
• Early and precise diagnostic
• Determination of severity • Incision, drainage
• Complication • Surgical debridement
• Risk factor • Broad spectrum AB
• Supportive care
• Identification of cause pathogen
Definition appropriate antimicrobial
• Empirical AM (before culture) = sensitive ( in culture results)
• Guidelines?
• Local antibiogram
• Decreasing mortality and morbidity
Antibiotic appropriate effect on cSSTI
Study
Irwanto R, Suhendro, Khie Chen 26 gram positive,59 gram negative: retrospective, P =0,45
Culture and non culture based AB cSSTI sepsis and non sepsis combined
are comparable

Jorg J Ruhe:cSSTI impact of Antimicrobial 531 cases episode cSSTI Appropriate 87% success
therapy on outcome Non-appropriate:87% failure
treatment

Marcus J Zervos: Epidemiology and 366 (81,5%) appropriate Same

Outcomes of cSSTI 83(18,5%)not appropriate Younger, MRSA, drug Abuse
Schramm GE: Theimpotnce of 492 patients Appropriate : 95% succes
appropriate initial antimicrobial Non-appropriate : 87% succes
treatment P=0,001

The UK’s National Institute for Clinical recommends monitoring of clinical progress and reassessment of treatment
Excellence based on culture findings

The Infectious Diseases Society of recommends bacterial culture assessment to aid the selection of antibiotics
America against the causative pathogens and initiate definitive
IDSA 2014 Recommendation
 Risk factors for different bacterial cSSTI
Methicillin-resistant Staphylococcus aureus Gram-negative, anaerobes and
• Anamnestic factors : polymicrobial
➢ Previous colonization • Surgical site infection:
➢ Contact with patients colonized
Age >75
➢ Axillary cavity
➢ Antibiotic therapy in the prevous 12 months Male ➢ Gastrointestinal tract
➢ Hospitalization in the previous 12 months Intra- hospital transfer ➢ Perineum
➢ History of previous infection ➢ Female genital tract
➢ Recent travel in Latin,America,Africa,South East Asia • Co- morbidities :
Hospitalization 1 year
➢ Residence in long term care facilities ➢ Diabetes mellitus
➢ Previous Intensive care unit admission ➢ Cirrhosis
History of IV th/1year
• Co-morbidities: ➢ Intravenous drug abuse
➢ Cardiovascular disease ➢ Subcutaneous drug abuse
Exposure to carbapenem
➢ Diabetes Mellitus
➢ Perpheral vascular disease Exposure to fluoroquin
➢ Chronic wounds
➢ Immunodepression Exposure to cephalosporin
➢ Central venous catheter
➢ Chronic renal disease Indwelling catheter
➢ Dialysis TOTAL > 5
➢ Intravenous drug abuse
 Cellulitis
• Very early and mild : oral beta lactam
• Severe: parenteral AB
▪ Cafazolin
▪ Vancomycin + piperacilin tazobactam or imipenem-meropenem (IDSA)
 SSI
• No systemic sign : incision & drainage (most important)
• Significant systemic response: antibiotic treatment
▪ Vancomycin : increase MIC <0,5 → 2mg/ml
▪ Linezolid:
o prospective study = vancomycin
o open label study : vancomycin lower cure rate- 67%
o many studies: more effective than vancomycin
o Inhibit toxin production
o Oral agent
Necrotizing infection
• Pyomyositis:
purulent, skeletal muscle, arise from hematogenous spread, usually with
abscess formation
▪ Incision + drainage
▪ AB:
- aztreonam , fluoroquinolon, aminoglycoside, 4th cephalosporin alone or
combination
- 1st cephalosporin + anti ESBL
- Anti MRSA

• Clostridial myonecrosis ( produce gas gangrene)

• → PNC + clindamycin
 Necrotizing Fasciitis
Type of infection
Necrotizing fasciitis by mixed pathogen Ampicillin sulbactam +
Clindamycin + ciprofloxacin
OR Piperacillin/tazobactam OR
Fluorpquinolon OR Carbapenem
OR 3rd Cephalosporin OR
Necrotizing fasciitis Antibiotic Choice
Aminiglycoside +anti anaerobic
agent Synergystic aerob &an Imipenem
Necrotizing fasciitis by GABHS(GroupA PNC + clindamycin OR aerob Meropenem
Beta hemolytic Sterptoccoccus) Glycopeptide OR Linezolid OR Piperacillin /
Tigecyline OR Daptomycin OR tazobactam
Dalbavancin PNC allergi Cefepime +
Necrotizing fasciitis by S. aureus 1st cephalosporin OR Metronidazole
Glycopeptides OR Linezolid OR Ciprofloxacin +
Tigecyline OR Daptomycin OR
Metronidazole
Dalbavancin
+ Vancomycin
/Daptomycin
 Pola Resistensi Kuman Rumah sakit Tipe A intensif
Pola Resistensi Kuman gram negative – PUS : Rumah sakit Tipe A Intensive
Pola Resistensi Kuman gram negative - LUKA : Rumah sakit Tipe A Intensive
Pola Resistensi Kuman gram negative - PUS : Rumah sakit Tipe A non
Intensive
Pola Resistensi Kuman gram positive - PUS : Rumah sakit Tipe A non Intensive
Pola Resistensi Kuman Pus: Rumah sakit Tipe B non intensif
Pola Resistensi Kuman Pus: Rumah sakit Tipe C non intensive & Intensive
Pola Resistensi Kuman SSTI RSUP H Adam Malik non intensif dan intensif

Ampisilin sulbacatam

cefoperazone -

cotrimoksazole
ciprofloksasin

Levofloksasin

vancomysine
meropenem

piperacilin -
tazobactam
tetracycline
Ceftriaxone

ceftazidime

clindamisin

gentamisin
sulbactam

doksisiklin
cefazoline

imipenem
Amikasin
SSTI

%
Resistance

n
ALL gram
negative 40 100 17,5 100 82,5 77,5 100 100 55 95 100 82,5 75 85 62,5 100 87,5 82,5 100
bacteria

E.coli 4 10 0 100 100 100 0 100 25 100 100 0 50 100 0 100 100 75 0

K.pneumonia 9 22,5 11,1 100 100 100 0 100 83 100 100 0 100 100 55,6 100 88,9 77,8 0

Pseudomonas
3 7,5 33 100 100 33 0 100 67 33 100 0 0 67 67 100 33 67 0
aeruginosa

Acinetobacter
15 37,5 33 100 100 100 0 100 73 100 100 5 93 100 93 100 100 100 0
baumanii

Proteus
2 5 0 100 0 0 0 100 0 100 100 0 0 0 0 100 50 100 0
mirabilis

Enterobacter
1 2,5 0 100 0 0 0 100 0 100 100 1 0 0 100 100 100 0 0
cloaceae

Aeromonas
3 7,5 0 100 33 33 0 100 33 100 100 1 67 33 67 100 100 33 0
hydrophilia

Serratia ficaria 1 2,5 0 100 100 100 0 100 0 100 100 0 100 100 100 100 100 100 0

Providentia
1 2,5 0 100 0 0 0 100 0 100 100 0 100 100 0 100 0 100 0
stuartii

Morganella
1 2,5 0 100 0 0 0 100 0 100 100 0 100 100 0 100 100 100 0
Morgani
 SSTI

us Sp.
gram +
All bacteria
Resitance

Staphylococc
n

5
8
%

100

62,5
Amikasin

100
100
Ampisilin sulbacatam

80
87,5
Ceftriaxone

80
87,5
ceftazidime

1
1

clindamisin

40
62,5

cefazoline
80
87,5

cefoperazone - sulbactam
100
100

ciprofloksasin
80
87,5

cotrimoksazole
80
87,5

doksisiklin
80
87,5

gentamisin
1
1

Levofloksasin
80
87,5

meropenem
100
100

tetracycline
40
75

piperacilin - tazobactam
100
100

imipenem
100
100

vancomysine
40
37,5
 S.
1 12,5 100 100 100 100 100 100 100 100 100 0 100 100 100 100 100 100 100
hemolitikus

S.aureus 1 12,5 100 0 0 0 0 0 100 0 0 100 0 0 100 0 100 100 0

S.hominis 1 12,5 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

S.pseud 1 12,5 100 100 100 100 0 100 100 100 100 100 100 100 100 0 100 100 0

S.epidermidis 1 12,5 100 100 100 100 0 100 100 100 100 100 100 100 100 100 100 100 0

Enterococcus
3 37,5 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 33
Sp

E. faecium 2 25 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 50

E.faecali 1 12,5 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 0
Checklist for early discharge of patients with acute
bacterial skin and skin-structure infection
Kesimpulan
1. cSSTI penyakit yang serius
2. Penanganan cSSTI adalah menghilangkan source infeksi dan
pemberian antibiotik
3. Pemberian antibiotik berdasarkan fokus infeksi dan stratifikasi
faktor resiko MDR
4. Antibiotik appropriate mengurangi mortalitas dan morbiditas
5. Antibiotik appropriate memerlukan data lokal