Professional Documents
Culture Documents
• Pendidikan
– Dokter umum – FK.UNPAD 1972
– Spesialis anak – FK.UI 1983
– Doktor – FK.UI 1996
– Guru Besar – FK.UI 2000
• Organisasi
– Ketua Indonesian Technical Advisory Group on Immunization (ITAGI)
– Anggota Satuan Tugas Imunisasi IDAI
– Anggota KOMNAS PP KIPI – KEMKES
– Board member of Asian Society of Pediatric Infectious Disease (ASPID)
– Member of Asia-Pacific Dengue Prevention Board (APDPB)
– Member of Asia Dengue Vaccine Advocacy (ADVA)
– President Elect of International Society of Tropical Pediatrics (ISTP)
General Principles of
Prudent Used of Antibiotics
The role of
pharmacy Bacteria
identification
General principles of the treatment
of infection
• Antimicrobial agents are among the most commonly
prescribed drugs.
• The major impact on control of most bacterial
infections
• Concerns that unnecessary use is compromising their
beneficial effect
• The choice of drug,
– Its dose, route, frequency of administration.
– Depend on the pharmacological & pharmacokinetic of
particular agent and adverse reactions of the drugs
Gallagher JC, Mac Douglall C. Antibiotics simplified, 2009
The benefit of antibiotic
Cure for
bacterial
infection only! Correct
dose &
Bacterial duration
elimination &
Suppress the eradication
number of
pathogen
Kill bacterial
pathogen caused
disease
Important questions to answer routinely
before selecting an antibiotic (1)
• Is an antibiotic indicated?
• Have appropriate specimen been obtained,
examined, and cultured?
• What organisms are most likely?
• If several antibiotics are available, which is best?
– Drug of choice, pharmacokinetics, toxicology, cost,
narrowness of spectrum, bactericidal compared with
bacteriostatic agents.
How to
choose the PK/PD? Side effect?
antibiotic?
How antibiotic kill bacteria?
Clinical assessment
• Clinical evaluation should define the anatomical
location and severity of the infective process.
• Although such diseases may be caused by wide
variety of organisms, the range of pathogens are
usually limited.
• The pattern of susceptibility reasonably predictable.
• Permits a rational selection of chemotherapy in the
initial management of such infections
Not indicated,
Increased likelihood Inappropriate antibiotics use,
of prescribing wrong Antibiotics of poor quality
medication and potency,
Inappropriately low doses
Strategies of Antibiotic Use
• Cure the infection completely
• Avoid pathogen transmission in the ward
• Established the clinical diagnosis and look for
proven cause
• Effective therapy and prudent use
• Follow the antibiotic usage guidance
• Training of antibiotic use (certified)
• Build the Hospital Committee of Antibiotic Use
(physician, pharmacy, board of hospital
managers)
Antibiotic Stewardship
• Explain the antibiotic resistance
• Increased hospital cost
Education • Follow the guidance
• Academic detailing to all prescriber
Selection
Depend on Extended Clinical
epidemiology empirical therapy judgement
Susceptibility test No bacterial
Prolonged empirical
No more than 72 therapy after 72 culture
hours hours Negative bacterial
culture but clinal
support to infection
Laboratory Assessment
• Few infective condition present a typical picture with
a definitive clinical & microbiological diagnosis
without laboratory examination
• Whenever possible a clinical diagnosis should be
supported by laboratory confirmation.
• Strong clinical suspected, therapy should be given as
soon as possible; while lab assessment should be
taken
• Serological test is important to antigen detection
Yes No
Pathogen identified?
Intravena
antibiotic
Clearly Clinical Improvement
C
Oral
Out patient
administration
Time of illness
Ramirez JA., 2002
Evaluation of
antibiotic use by
Gyssen
Quality of Antibiotic Use
assessment by Gyssens Criteria
Category
I No indication for giving the antibiotic
II Correct indication but incorrect dose, interval and
route of antibiotic use
III Correct indication with correct dose, interval, route but
not incorrect in duration of antibiotic use
IV Correct indication with correct dose, interval, route but
and duration of antibiotic use, but incorrect of
selecting the antibiotic
Outpatient Parenteral Antibiotic Therapy
(OPAT)
• Assessment before starting therapy
– patient’s general medical condition,
– the infectious process,
– the home situation is necessary
• These responsibilities
– include establishing a diagnosis,
– prescribing treatment,
– determining the appropriate site of care,
– monitoring during therapy,
– assuring the overall quality of care
Outpatient Parenteral Antibiotic Therapy
(OPAT)
37.50 C
Evaluation
Clinical
Lab/CXR Cured
LP, etc
1 2 3 4 5 6 7 8 9 10
Day of illness
Antibiotic Failure
Suhu 0C
Antibiotic th/ Adjusted therapy
Fever persist
?
37,5
WBC Complications
Conciousness Transaminase Other focal inf
Complications CXR Ab resistance
Other signs/symptoms LP, CT-scan, etc Suboptimal dose
Wrong D/
Drug fever
0 1 2 3 4 5 6 7 8
Hari rawat
Inappropriate use of antibiotics
Increase in
antibiotic use Increase in
resistant strains
Limited treatment
alternatives
• more antibiotics
• increased Ineffective empiric
mortality therapy
• increased morbidity
• more antibiotics
Increased use
of healthcare Increased
resources hospitalization
• more antibiotics
The Alliance for the Prudent Use of Antibiotics (APUA)
The CDC 4 Strategies Campaign to Prevent
Antimicrobial Resistance in Healthcare settings
Prevent infection
Preventing infections and complications will
decrease antimicrobial use
Prevent transmission
Health care personnel can prevent the spread
infections from patient to patient.
1. Prevent Infection
– Step 1. Vaccinate hospitalized children and staff
– Step 2. Get the devices out
43
12 Steps to Prevent Antimicrobial
Resistance Among Hospitalized Children
3. Use Antimicrobials Wisely
– Step 6. Practice antimicrobial control
– Step 7. Use local data
– Step 8. Treat infection, not contamination or colonization
– Step 9. Know when to say “no”
– Step 10. Stop treatment
4. Prevent transmission
– Step 11. Practice infection control
– Step 12. Practice hand hygiene
44
Multi disciplinary Approach
• Collected data based and identifies the problems
• The strategy of antibiotic use
• Drug formularium
• Antibiotic use guidelines
• Restricted the use of antibiotic, prior approval for
certain antibiotic
• Use and follow the clinical pathways
• Post prescribing evaluation
• Switching-intravenous to oral conversion
• Prescriber education- academic detailing
Paskovaty, Pflomm,Myke, Seo,2005
Summary
• Antibiotic use should depend on indication
either clinical or lab result
• Guideline of indication and selecting antibiotic
is mandatory
• Antibiotic use in each patient should be
evaluated
• Supporting therapy needed to get a maximal
result
• Prudent antibiotic use will give better patient
care beside prevented the antibiotic resistance
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