GLOBAL DAN NASIONAL

PROBLEM AMR

What next?

KPRA KEMNENKES RI
• Multi national AMR surveillance indicate, increasing
prevalence of AMR- ESBL/MRSA/CRE/NDM-`1
500.000.000 Inhabitance 300.000.000 Inhabitance
MR: 25.000/Year MR: 23.000/Year
COST: US$ 20 B/Year COST: € 1.5 B/Year

70.000.000 Inhabitance
MR: 38.000/Year
COST: € 1.3 B/Year

• Multi national mortality surveillance showed, incidence

of MR and cost among the countries. WHO, 2013
 DAMPAK AMR - HAI
• Morbidity &mortality
• Failure of complex operation
• ALOS
• Global spreading of AMR
• disability and work capacity
• Global mortality
• 700.000/year (2013)
• 10.000.000/year (2050)
•2050 - Global cost  US $100 T/year
(Jim O Neil, 2015) 2050
 MAY 2015

1. to improve awareness and understanding of

antimicrobial resistance;
2. to strengthen knowledge through
surveillance and research;
3. to reduce the incidence of infection;
4. to optimize the use of antimicrobial agents;
and
5. develop the economic case for sustainable
investment that takes account of the needs
of all countries, and increase investment in
new medicines, diagnostic tools, vaccines
 What is AMR?

Antimicrobial resistance
(AMR) is the ability of
microorganisms that cause
disease to withstand attack
by antimicrobial medicines
β-lactamases breaking of the β-lactam ring β-lactam antibiotics
that inactivate β-lactam antibiotic, breaking its amide bond, so
the obtained products stopped antibacterial activity wtih class of
penicilins and cephalosporins.

Antônio José Rocha et al. Review - Human & Animal Health 2019
The more we give, Apa pemicu
the more we lose resistensi?
• Peningkatan penggunaan AB
• Misuse dan overuse
• Penggunaan profilaksis terlalu
tinggi jenis dan terlalu lama
• AB untuk infeksi virusion
• Penjualan bebas
• Penyebaran di rumah sakit
• Antibiotics dalam pakan ternak
Ammar Ahmad Khan et al, Journal Of Food Processing And Preservation 2015; Alah H. Abou-raya
Journal of Food and Drug Analysis, Vol. 21, No. 1, 2013
The Best Chain Restaurants for Antibiotic-Free
Meat
By: Sophie Johnson | EatingWell.com, October 2017
Mutasi dan selective pressure
NATIONAL PROBLEM ON AMR
 The prevalence of ESBL producing E.coli and Klebsiella pneumoniae in hospitals. Indonesia

Year 2013 Year 2017

40% 60%
(26.7%-56.8%) (50%-82%)
82% 79%
78%

56.8
51.69 53% 52% 55% 56%
50%
40.83 37.82 The prevalence of ESBL
27.94 26.71
producing E.coli and Klebsiella
pneumoniae among nine
hospitals in Indonesia,

RSDS RSSA RSDM RSDK RSSD RSP ACH MED JAK SEM SOL SUB MAL DPS

AMR and AMU’s Study : dr. Soetomo Surabaya hospital National Institute of Health Research and Development (NIHRD)
with WHO support at Teaching Hospitals in Indonesia (2013), and in 2016-2017 support by MoH
 Antibiotic Use Surveillance in Teaching Hospital
Year 2005 Year 2017

50-80% 60-80%
Inappropriate Antibiotic Use at Hospitals

Evaluator range 100

80
Category Surabaya Semarang
(%) (%) 60

No indication 40
45 - 76 56 - 76
(treatment) 20
No indication 0
(prophylaxis)
13 - 55 43 - 76 0 I II III IV V VI
RS A RS B RS C RS D RS E RS F

• AMRIN Study report. 2005

• Evaluation antibiotic qualitative use by Gyssens method, ARCC-MoH 2017
 Antibiotic susceptibility (n) pattern of ESBL producing E.coli andK.pneumoniae

Year 2013
Study in 6 teaching hospital

<0,78-15% RSDS RSSA RSDM RSDK RSSD RSP TOTAL

Cefotaxime 0.17 0.00 NA 1.57 3.31 NA 0,78
Cephalosphorine 3rd 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
generation susceptible to
Cefepime 0.34 42.06 26.21 9.42 25.62 0.00 12,78
ESBL 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
<17% Piperacillin-
tazobactam
49.57 76.19 NA 76.44 65.81 66.67 60,4
Cefoperazone-
Levofloxacin susceptible to sulbactam
53.85 NA 83.33 72.73 57.98 15.63 57,08
ESBL 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
17
18
“Common infections and minor
injuries which have been
treatable, can kill any one”

Dr. Keiji Fukuda, (WHO).

 SEVERE MORBIDITY AND
MORTALITY
DATE AntibiotiC
NY. E; 35 TAHUN. P1-1,
Spontan delivery; 2600 g; perineal
rupture grade IV
18 – 19 April Inj Ceftriaxone 1 gram /12
2019 hrs
20 – 27 April Inj Levofloxacin 750 mg
2019 /24 hrs
28 – 30 April Inj Meropenem 1 gram
2019 /24 hrs

4 May Dead, e.c Sepsis

 DASAR REGULASI PPRA
PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA
NOMOR 2406 / MENKES / PER /XII/2011, TENTANG
PEDOMAN UMUM PENGGUNAAN ANTIBIOTIK

PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA

NOMOR 8 TAHUN 2015 , TENTANG
PROGRAM PENGENDALIAN RESISTENSI ANTIMIKROBA DI
RUMAH SAKIT FASILITAS KESEHATAN
 PERMENKES NO 8/2015. (PPRA)
Pasal 6
• Setiap rumah sakit harus melaksanakan Program Pengendalian Resistensi
Antimikroba secara optimal.

Pasal 3
• Strategi Program Pengendalian Resistensi Antimikroba dilakukan dengan
cara:
• mengendalikan berkembangnya mikroba resisten akibat tekanan
seleksi oleh antibiotik, melalui penggunaan antibiotik secara bijak;
dan
• mencegah penyebaran mikroba resisten melalui peningkatan ketaatan
terhadap prinsip pencegahan dan pengendalian infeksi.
Pasal 11
• Indikator mutu Program Pengendalian Resistensi Antimikroba di
Rumah Sakit meliputi:
• perbaikan penggunaan antibiotic (kuantitas dan kualitas)
• perbaikan pola kepekaan antibiotik dan penurunan pola
resistensi antimikroba;
• penurunan angka kejadian infeksi (HAI) di rumah sakit yang
disebabkan oleh mikroba multiresisten; dan
• peningkatan mutu penanganan kasus infeksi secara
multidisiplin, melalui forum kajian kasus infeksi terintegrasi.
Kebijakan penggunaan antibiotik di rumah sakit
Tatalaksana pengunaan Supporting
antibiotik
• Monitoring dan audit -
• Diagnosis pasti: infeksi
bakteri ASP
• Pemeriksaan • Surveillans AMR dan
lab/mikrobiologi AMU
• Antibiotik Empirik • Pola bakteri dan
• Antibiotik definitif kepekaan antibiotik
• Antibiotik profilaksis
• Pelaporan
• Pembagian antibiotik
• Sandarisasi PPK- SMF
• Persetujuan peresepan
antibiotik
 ASP Challenges ..!
• 40.000 pneumonia cases,
• 27.000 patient with
inappropriate antibiotic
prescription for
• Physicians behavior on antibiotic pneumonia. In USA 2010.
prescribing
• Hand hygiene among healthcare staff
• Diagnostic: Clinical Microbiology
Services
 The impact of ASP Implementation
towards reducing ESBL

Pena et al, 1998. Epidemiology and Successful Control of a Large Outbreak Due to Klebsiella pneumoniae Producing ExtendedSpectrum β-Lactamases
ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Jan. 1998
 Antibiotic Stewardship Program
Intervention for
• optimizing use of
antibiotic  correct
type, dose, route,
interval and duration.
• accurate indication
• with appropriate
procedures
• Increase patient
outcomes
The requirements
• GUIDELINE
• Grouping of antibiotic:Access,
Watch and Reserve
• Authority for approval antibiotic
• Monitoring and feedback
• LEADERSHIP and managerial
support

Ohl CA. Seminar Infect Control 2001;1:210-21.

Ohl CA, Luther VP. J. Hosp. Med. 2011;6:S4
Dellit TH, et. al. Clin Infect Dis. 2007;44:159-177

Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ,
2016. Implementing an antibiotic stewardship program: guidelines by the
29
infectious diseases society of America and the society for healthcare
epidemiology of America. Clin Infect Dis.
 Antibiotic Stewardship Program: The Steps
Develop policy,
2
Form
1 antibiotic
stewardship
guideline, or
clinical pathway
committee.

• Surgical

3 4 5 •
prophylaxis
Empiric:
Carbapenem,
vancomycin
• CAP – Children/
Create awareness Implement adult
Start with a
and understanding
certain priority at the
through education
and training area priorities
 Antibiotic Stewardship Program: ACTIVITY
Dr. Djovi. SpPD
RS. Super husada

R/ Meropenem
1 g no X
/ imm.

Ny. Rindu

Ms. Rindu. 46
yrs Discussion:
BP110/70,
TEMP: 38.5,
ASP Meronem

Leucosit: 14.000.
X-Ray Thorax:
Team Levofloxaci
Pneumonia (+) n 750 mg
Diagnose: CAP
Persetujuan peresepan antibiotik

Pasien Perawat

ACCES Farmasist
PPDS
RESEP WATCH Farmasist
DPJP
RESERVE Tim ASP
tidak sesuai
 PEMBAGIAN ANTIBIOTIK
(WHO Antibiotic list 2018)

•ACCES antibiotik yang direkomendasikan sebagai terapi

empirik infeksi pada umumnya, selalu tersedia, harga terjangkau,
mutu terjaga.
•WATCH antibiotik yang berpotensi memicu resistensi,
direkomendasikan digunakan sebagai empiric kasus tertentu.
Penggunaannya harus dipantau oleh tim ASP
•RESERVE: antibiotik yang diperuntukan sebagai pilihan
terakhir, pasien khusus (gawat, darurat, mengancam nyawa)
penggunaannya harus melalui kajian dan pemantauan tim ASP.
 Antibiotic Groups (draft AB Guideline- KEMENKES-2019)

ACCESS WATCH RESERVE

Amoksisilin, Ampisilin Amikasin Aztreonam
Amoksisilin-asam klavulanat Azitromisin Meropenem
Ampisilin-sulbaktam Klaritromisin Seftarolin
Benzatin benzilpenisilin Levofloksasin Polimiksin B
Sefaleksin Moksifloksasin Polimiksin E (colistin)
Sefadroksil Siprofloksasin Piperasilin-tazobaktam
Sefazolin Sefiksim Linezolid
Kloksasilin Sefotaksim Tigesiklin
Prokain penisilin Seftriakson Vankomisin
Gentamisin Seftazidim Kotrimoxazol inj
Kloramfenikol Sefepim Teicoplanin
Klindamisin oral Fosfomisin Daptomisin
Doksisiklin
Eritromisin
Siprofloksasin oral
Tiamfenikol
Metronidazol
Trimethoprim+sulfametoksazol
(kotrimoksazol oral)
 INDIKATOR KEBERHASILAN PROGRAM NASIONAL

MISUSE & OVERUSE

Of Antibiotic

WHO 13th 80 % 70 %
General 60 %
Programme of 50 %
60 %
Work (GPW 13)

50 %
Targets and 40 %
Indicators AMR: ESBL 30 %
(29 October
2018)
2018 2023 2028 2033
Berbuat baik itu….. tidak baik

yang baik adalah…. berbuat lebih baik

HAP & JOS 2019