Week 4

• Antimicrobial


  Pharmaceutical agents that include antibacterial, antifungal, antiviral, and antiparasitic drugs
• Antibiotic


  Chemical substances produced by various microorganisms (bacteria, fungi, actinomycetes) that have the capacity to inhibit or destroy other microorganisms
• Antibiotics are chemically synthesized
• Antibiotics will not cure infections caused by viruses
• Classification of antibiotics by mechanism of action

  • Inhibition of cell wall synthesis
  • Inhibition of protein synthesis
  • Inhibition of DNA synthesis
  • Inhibition of folate metabolism
  • Inhibition of RNA synthesis
• Classification of antibiotics by spectrum

  • Narrow spectrum (acting on one group either Gram +ve or Gram -ve)
  • Broad spectrum (acting on both Gram +ve and Gram -ve)
• Bactericidal


  Kills bacteria, reduces bacterial load
• Bacteriostatic


  Inhibit growth and reproduction of bacteria
• All antibiotics require the immune system to work properly
• Bactericidal antibiotics are appropriate in poor immunity, while bacteriostatic antibiotics require an intact immune system
• Time-dependent killing


  The time it takes for a pathogen to be killed by exposure to an antimicrobial. The major pharmacokinetic/pharmacodynamic parameter that correlates with clinical and bacteriologic efficacy is the time for which the serum concentration exceeds the MIC of the pathogen.
• Concentration-dependent killing


  The major pharmacodynamic parameters that correlate with clinical and bacteriologic efficacy are the 24-h area under serum drug concentration curve (AUC) to MIC ratio, or the peak drug concentration to MIC ratio, based on free or unbound serum concentration values.
• Lipophilic


  The ability of a substance to dissolve in lipids or fats. Lipophilic substances are nonpolar and affect the potency of a drug to distribute throughout the body and to eliminate from the body.
• Hydrophilic


  The ability of a substance to dissolve in water or other hydrophilic solvents. Hydrophilic substances are essentially polar molecules.
• Antimicrobial stewardship (AMS)


  The optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance.
• Antibiotic use contributes to the development of antibiotic resistance, which affects the patient, future patients, and the wider community.
• Modern medicine, especially surgery and cancer treatments, depends on effective antibiotics to minimize the risk of infection.
• Antimicrobial resistance results in substantial financial cost for patients and healthcare systems.
• Goals of antimicrobial stewardship

  • Improving patient care/outcome
  • Reducing collateral damage (e.g. C. difficile infection)
  • Optimizing healthcare costs
• Core elements for developing successful antimicrobial stewardship

  • Leadership commitment
  • Accountability
  • Drug expertise
  • Action
  • Tracking
  • Reporting
  • Education
• An antimicrobial stewardship program is a systematic approach to implement a range of activities to achieve the goals of antimicrobial stewardship.
• Who needs antimicrobial stewardship?

  • Hospitals
  • Long-term care facilities
  • Outpatient settings
• Composition of an antimicrobial stewardship committee

  • Infectious disease physician
  • Clinical pharmacist with infectious disease training
  • Infection preventionist
  • Hospital epidemiologist
  • Information technology specialist
  • Microbiologist
  • Quality improvement specialist
  • Administrative representative
• In Indonesia, the Ministry of Health regulation No. 8/2015 requires every hospital to implement an Antimicrobial Resistance Control Program, which includes forming an antimicrobial resistance control team.
• Setiap rumah sakit harus melaksanakan Program Pengendalian Resistensi Antimikroba secara optimal
• Pelaksanaan Program Pengendalian Resistensi Antimikroba

  1. Pembentukan tim pelaksana Program Pengendalian Resistensi Antimikroba

  2. Penyusunan kebijakan dan panduan penggunaan antibiotik

  3. Melaksanakan penggunaan antibiotik secara bijak

  4. Melaksanakan prinsip pencegahan pengendalian infeksi
• Tim pelaksana Program Pengendalian Resistensi Antimikroba


  Dibentuk melalui keputusan kepala/direktur rumah sakit, terdiri atas ketua, wakil ketua, sekretaris dan anggota
• Kualifikasi ketua tim PPRA


  Seorang klinisi yang berminat di bidang infeksi
• Tim pelaksana Program Pengendalian Resistensi Antimikroba bertanggung jawab langsung kepada kepala/direktur rumah sakit
• Pencegahan dan Pengendalian Resistensi Antibiotik tidak hanya dilakukan di rumah sakit tetapi juga di Puskesmas/Klinik/Dokter Swasta
• Indikator


  • Penggunaan antibiotik: kualitatif dan kuantitatif
  • Perbaikan pola kepekaan antibiotik dan penurunan resistensi
  • Menurunkan kejadian infeksi mikroba multiresisten di rumah sakit
  • Meningkatkan kualitas penanganan infeksi secara multidisiplin
• Langkah implementasi AMS di Rumah Sakit

  1. Kebijakan rumah sakit

  2. Pembentukan Tim AMR

  3. Menyusun perencanaan program

  4. Implementasi

  5. Monitoring dan evaluasi
• Program Perencanaan


  1. Penentuan pilot project implementasi PPRA

  2. Sosialisasi PPRA di area pilot project

  3. Telaah panduan antibiotik dan protokol penatalaksanaan infeksi

  4. Studi operasional: memperoleh data objektif dan valid

  5. Analisis data

  6. Pemutakhiran panduan
• Anggota Tim AMR di Rumah Sakit


  • Komitmen
  • Klinisi
  • Ahli Penyakit Infeksi
  • Program Pengendalian Antimikroba
  • Farmasi
  • Sistem Informasi
  • Keselamatan Pasien & Mutu
  • Mikrobiologi
• Fungsi utama Tim AMR di Rumah Sakit

  • Peningkatan kuantitas penggunaan antibiotik
  • Peningkatan kualitas penggunaan antibiotik
  • Perbaikan pola kepekaan antibiotik dan penurunan pola resistensi antimikroba
  • Penurunan kejadian infeksi di rumah sakit yang disebabkan oleh mikroba multiresisten
  • Peningkatan kualitas penanganan kasus infeksi secara multidisiplin, melalui penyelenggaraan forum kajian kasus infeksi terintegrasi
• Penatagunaan Antimikroba (PGA), atau Antimicrobial Stewardship (AMS) adalah kegiatan strategis dan sistematis, yang terpadu dan terorganisasi di RS, untuk tujuan mengoptimalkan penggunaan antimikroba secara bijak, baik kuantitas maupun kualitasnya, menurunkan tekanan selektif terhadap mikroba, sehingga dapat mengendalikan resistensi antimikroba
• Data yang diperlukan oleh PGA

  • Surveilans HAIs
  • Audit kuantitatif penggunaan antimikroba
  • Audit kualitatif penggunaan antimikroba
  • Antibiogram
  • Biaya penggunaan antimikroba
• Elemen utama PGA


  • Kebijakan Rumah Sakit
  • Formularium Rumah Sakit
  • Panduan praktik klinis
  • Data
• Antibiotik kategori Watch


  • Amikasin
  • Azitromisin
  • Fosfomisin (oral)
  • Klaritromisin
  • Levofloksasin
  • Moksifloksasin
  • Sefiksim
  • Sefoperazon-sulbaktam
  • Sefotaksim
  • Seftazidim
  • Seftriakson
  • Siprofloksasin (inj)
  • Polimiksin E (oral)
• Antibiotik kategori Reserve


  • Aztreonam
  • Daptomisin**
  • Fosfomisin (inj)
  • Kotrimoksazol (inj)
  • Linezolid
  • Meropenem
  • Piperasilin-tazobaktam
  • Polimiksin B**
  • Polimiksin E (inj)**
  • Sefepim
  • Seftarolin
  • Teikoplanin
  • Tigesiklin
  • Vankomisin