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Peran pilar PPI dalam Program

Pengendalian Resistensi
Antimikroba (PPRA)

Najatullah
Tim PPIRS
Mengapa penting MDRO dikendalikan ?

Increasing clinical problem


They cause outbreaks, particularly in critical
areas e.g. ICUs, neonatology
Often multi-resistant - can be difficult to treat
Associated with increased mortality
Associated with increased LOS
Sejarah pengendalian infeksi
1950 1980

Infeksi teratasi Infeksi


dengan baik masalah global

Pengembangan antibiotik
antibiotik baru baru terhambat
Dana riset penemuan
++ antibiotik sangat terbatas
Resistensi semakin meningkat
Kecepatan
penemuan
antibiotik

Timbulnya
resistensi
kuman

- Post antibiotic era


- Kembali ke zaman
pra antibiotik
- Peningkatan kematian
karena penyakit infeksi
Bagan
Spekulatif
Waktu
AMRIN STUDY : tahun 2002

Prosentase E. coli resisten


pada pasien Masuk & Keluar Rumah sakit

25

20

15
MRS
10 KRS

0
Genta Cefotax Genta Cefotax

Surabaya Semarang
Antimicrobial Prescribing Profile
Dr.Soetomo & Dr. Kariadi Hospital in 2002

Evaluation
Category
Sby (%) Semarang (%)

No Indication for
theraphy 55 - 80 20 - 53

No indication for
prophylaxis 13 - 55 43 - 81

AMRIN STUDY : 2002 6


ESBLs & VRE association with hospital size and complexity
Diekema et al, Clin Infect Dis 2004; 38: 78-85
ESBLs & VRE association with hospital size and complexity
Diekema et al, Clin Infect Dis 2004; 38: 78-85
Pengendalian
Resistensi

Penggunaan
Pencegahan Antibiotik
1 Seleksi secara
Bijak

Pencegahan
2 Penyebaran Ketaatan prinsip
Kewaspadaan
Standar
Selection

10
Konsep Dasar PPRA
SMF
SMF

PPI FARMASI
SMF
SMF

PPRA
SMF
SMF
MIKROBIOLOGI
KLINIK
KFT

SMF SMF
Program
Pengendalian Resistensi Antimikroba

Identifikasi kesiapan 4 pilar

KFT / KOMED
FARMASI KLINIK
MIKROBIOLOGI
KLINIK

PPI
KOMITMEN / KONSENSUS
Komite/ Tim PPI

Pengendalian penyebaran mikroba resisten


Standar Precaution (kewaspadaan
standar)
Isolasi/kohort isolasi pasien
Penanganan unit kerja sumber
mikroba resisten /source control
Surveilans mikroba resisten
Menyusun pedoman terkait
Masalah
Misuse
Antibiotik

Under
Antibiotik

Overuse Kuman
Antibiotik resisten
..EVOLUTION OF ANTIBIOTIC
RESISTANCE: Rate of Development

The therapeutic life span of a drug is based on


how quickly resistance develops.
The more an antibiotic is used, the more
quickly resistance occurs.
..EVOLUTION OF ANTIBIOTIC
RESISTANCE: Rate of Development
Resistance develops at different rates.
Several groups of antibiotics were used for many
years before resistance was seen.
Resistance to penicillin was seen in only three
years.
Some semi-synthetic forms of penicillin
(ampicillin) had a relatively long time before
resistance developed.
Other semi-synthetic forms (methicillin) lasted
only a year before resistance developed.
Short interval is directly related to increased use.
..EVOLUTION OF ANTIBIOTIC
RESISTANCE: Rate of Development
..EVOLUTION OF ANTIBIOTIC
RESISTANCE: Overuse

The most important contributing factor for


resistance is overuse.
A good example is prescribing antibiotics that
dont kill viruses for the common cold.
These antibiotics do destroy the normal flora.
Opportunistic pathogens that are resistant survive
and can take hold.
Definitions :
antibiotik yang diberikan pre-saat-setelah operasi pada kasus yang secara klinis tidak
terdapat tanda infeksi. Tujuannya untuk mencegah terjadinya ILO / SSI

Infection here may cause:

Delayed healing

Hernia
Possible evisceration

Abscess
Fistula
Other procedures needed
Audit Penggunaan Antibiotik
Di Rumah Sakit

Kuantitatif
DDD/100 patient days
Multiple
reviewer
Kualitatif
Metode Gyssens

21
Persiapan penderita operasi
elektif/terencana
Di ruangan
kadar gula darah dipastikan <200 mg/dl
pasien bisa tidur cukup, apabila pasien gelisah dapat
diberikan obat sleep inducer
pasien mandi + keramas menggunakan sabun
pasien yang tidak bisa mobilisasi dilakukan bed-bath
pasien di cukur (bukan dikerok) menjelang berangkat
ke kamar operasi. Khusus bagi pasien operasi
membuka kepala (craniotomy) dianjurkan dicukur di
Kamar operasi. (risiko ILO 3 kali lebih rendah)
Di kamar operasi
hangatkan pasien, pasien hipotermi
meningkatkan risiko infeksi 2 kali lipat
pasien mendapat oksigenasi cukup
(menurunkan risiko ILO 2 kali)
beri antibiotik profilaksis intravena, 30 menit
sebelum insisi dan secara drip selama 15-30
menit
Van der meer and Gyssens, 2001

start

no
Sufficient
VI stop
data ?

yes

no
AB Indicated ? V stop

24
yes
more effective
IV a
Alternative ?

No

yes
Alternative
IV b
less toxic ?

No

yes
Alternative IV c
less costly ?

No

Alternative yes
Narrowerer ? IV d

No 25
No
Duration Duration
too long ? too short ?

yes yes

III a III b

26
Correct No
II a
Dose ?

yes
Correct No
II b
Interval ?

yes
No
Correct Route ? II c

yes

Correct Timing? No I
(profilaxis)

27
yes

If not in
Categories I-IV

yes

28
I = Tidak tepat saat pemberian antibiotik
Kategori II A= Tidak tepat dosis
Kualitas II B= Tidak tepat interval pemberian
Antibiotik II C= Tidak tepat rute pemberian
IIIA= Pemberian terlalu lama
IIIB= Pemberian terlalu singkat
IVA = Ada antibiotik lebih efektif
IVB = Ada antibiotik kurang toksik
(lebih aman)
IVC = Ada antibiotik lebih murah
IVD = Ada antibiotik spektrum lebih sempit
V = Tidak ada indikasi
VI = Rekam medik tidak lengkap/
tidak dapat dievaluasi
Contoh :
(DDD Ampicillin: 2 gr; Ceftriaxon: 2 gr)

Px. Rejimen antibiotik LOS Total DDD

P1. Ampi 3 x 1 gr (10 hr) 15 hr 30 gr 30/2 = 15


P2. Ampi 4 x 500 mg (5 hr) 10 hr 10 gr 10/2 = 5
P3. Ampi 2 x 1 gr (10 hr) 10 hr 20 gr 20/2 = 10
P4. Ceftri 1 x 2 gr (5 hr) 10 hr 10 gr 10/2 = 5

Total 45 hr Ampi = 30, Ceftri = 5


DDD (100 patient-days) Ampi:30/45 X 100 = 66,6
Ceftri: 5/45 x 100 = 11,1

30
Transmission
Air
Droplets
Contact
Water
Food
Blood
Vectors
Prevention and Control
Depends on appropriate clinical practices that
should be incorporated into all routine patient
care
Eradication and control of MDROs, frequently
required periodic reassessment and the
addition of new and more stringent
interventions over time (tiered strategy)
Control Interventions
The various types of interventions used to
control or eradicate MDROs may be grouped
into seven categories :
1.Administrative support,
2.Judicious use of antimicrobials,
3.Surveillance (routine and enhanced),
4.Standard and Contact Precautions,
5.Environmental measures,
6.Education,
7.Decolonization
Administrative support Isolation
AB policy Cohorting
PATIENT Manage the wound

Surveillance
ENVIRON
HCP MENT

Implementasi ppi Environment control


Decolonization
Prudent use of AB
1.Administrative support
Administrative commitment of fiscal and
human resources
Providing the necessary number and appropriate
placement of hand washing sinks and alcohol-containing
hand rub dispensers in the facility
Maintaining staffing levels appropriate to the intensity of
care required
Implementing system changes to ensure
prompt and effective communications
Enforcing adherence to recommended infection control
practices
2.Education
The focus of the interventions was to
encourage a behavior change
Change involved hand hygiene, antimicrobial
prescribing patterns
Facility-wide, unit-targeted, and informal can
be more effective
3.Judicious use of antimicrobial agents
This effort targets focuses on effective
antimicrobial treatment of infections
use of narrow spectrum agents,
treatment of infections and not contaminants,
avoiding excessive duration of therapy, and
restricting use of broad-spectrum or more potent
antimicrobials to treatment of serious infections
when the pathogen is not known or when other
effective agents are unavailable
Strategies for influencing antimicrobial
prescribing patterns include:
education; formulary restriction; prior-approval
programs, including pre-approved indications;
automatic stop orders; academic interventions to
counteract pharmaceutical influences on
prescribing patterns; antimicrobial cycling,
computer-assisted management programs; and
active efforts to remove redundant antimicrobial
combinations
4.MDROs surveillance
Critically important component
allowing detection of newly emerging pathogens,
monitoring epidemiologic trends, and measuring
the effectiveness of interventions
Surveillance for MDROs:
1.Isolated from routine clinical cultures
Antibiograms
Incidence Based
Infection Rates
Molecular typing of MDRO isolates
2.Detecting asymptomatic colonization by active
surveillance culture
5.Infection Control Precautions
Since 1996 CDC has recommended the use of
Standard and Contact Precautions for MDROs
Standard Precautions
Must be used in order to prevent transmission from
potentially colonized patients
Hand hygiene is an important component
Contact Precautions
prevent transmission of infectious agents, which are
transmitted by direct or indirect contact with the
patient or the patients environment
A single-patient room is preferred for patients
who require Contact Precautions
When a single-patient room is not available,
consultation with infection control is necessary
to assess the various risks associated with other
patient placement options (e.g. cohorting,
keeping the patient with an existing roommate)
Should wear a self-protecting device
Cohorting
cohorting of patients
cohorting of staff
use of designated beds or units
unit closure
6.Environmental measures
Monitoring for adherence to recommended
environmental cleaning practices is important
to controlling transmission of pathogens in the
environment
Environmental cultures are not routinely
recommended
7.Decolonization
Decolonization entails treatment of persons
colonized with a specific MDRO, usually MRSA,
to eradicate carriage of that organism
Decolonization of persons carrying MRSA in
their nares has proved possible with several
regimens that include topical mupirocin alone
or in combination with orally administered
antibiotics
Decolonization regimens are not sufficiently
effective to warrant routine use
Several factors limit the utility of this control
measure on a widespread basis:
1) identification of candidates for decolonization requires
surveillance cultures;
2) candidates receiving decolonization treatment must
receive follow-up cultures to ensure eradication; and
3) recolonization with the same strain, initial colonization
with a mupirocin-resistant strain, and emergence of
resistance to mupirocin during treatment can occur
HCP implicated in transmission of MRSA are
candidates for decolonization and should be
treated and culture negative before returning
to direct patient care
In contrast, HCP who are colonized with
MRSA, but are asymptomatic, and have not
been linked epidemiologically to transmission,
do not require decolonization
Management of an Outbreak

Definition of MDRO Outbreak/Epidemic:


When a facility has an initial case of MDRO
Or a substantial increase in the number of
cases in a facility.
Each facility must decide the criteria to define
an outbreak in their institution.
Deteksi KLB
Lakukan investigasi secara cepat
Kaji ulang data surveilans
Wawancara dengan klinisi/petugas laboratorium
Lihat laporan mikrobiologi
Lakukan verifikasi diagnosis
Berikan definisi kasus berdasarkan:
Data mikrobiologi
Gejala/tanda klinis
Pemeriksaan laboratorium klinis
Memastikan kasus
Deskripsi epidemiologi
Tetapkan masalah,populasi resiko,lokasi,keparahan
Tetapkan munculnya KLB
Tetapkan langkah pengendalian
Evaluasi terhadap keefektifan langkah
pengendalian
Buat laporan
Various types of interventions used to control or
eradicate MDROs

Administrative support
Education
Judicious use of antimicrobial agents
MDRO surveillance
Infection Control Precautions
Environmental measures
Decolonization
Administrative support
Membuat kebijakan dan regulasi terkait
dengan penggunaan antimikroba
Mengimplementasikan dan memantau
kepatuhan pelaksanaan
Menyediakan kebutuhan sarana terkait,
wastafel, handrub dll
Memantau mutu air, udara, lingkungan RS
Dll
Education
The focus of the interventions was to
encourage a behavior change through
improved understanding of the problem
MDRO
Facility-wide, unit-targeted, and informal,
educational interventions were included
MDRO surveillance
Allowing detection of newly emerging
pathogens, monitoring epidemiologic trends,
and measuring the effectiveness of
interventions
Case Finding
Target :
Individu terinfeksi
Individu terkolonisasi
Case Finding
Metode
Surveilans aktif infeksi di RS
Laporan dari petugas infeksi di RS
Informasi dari lab. Mikrobiologi
Infeksi di RS
Infeksi di luar RS (kasus impor)
Infection Control Precautions
Standard Precautions
Contact Precautions
Cohorting and other MDRO control strategies
Pencegahan Transmisi
Kewaspadaan baku cuci tangan, dll

Isolasi barrier fisik & fungsional


* Kontak
* Droplet
* Airborne

Pemantuan koordinasi lab Mikrobiologi,


Klinisi
Terima kasih