Antimicrobial Resistant (AMR), Antimicrobial Use (AMU) and Antimicrobial

Stewardship Program (ASP)/Program Penatalayanan Antimikroba (PPA)

RSUP Dr. Hasan Sadikin Model, Bandung.

Uun Sumardi

ARCP/PPRA RSUP Dr. Hasan Sadikin, Bandung.

WS PPA 2017
 OBJECTIVES
• What is antimicrobial resistance (AMR)
• Why AMR is a concern
• Antibiotic Use (AMU in KARS and JCI 6ed)
• AMU (Quality and Quantity) in RSUP dr. Hasan Sadikin
• Antimicrobial Stewardship Program (ASP)
• Indonesia National Action Plan (NAP) on AMR
• Program Penatalayanan Antimikroba sebagai Hospital Action Plan (HAP) di
RSUP dr. Hasan Sadikin (PPA/ASP HAP RSUP dr. Hasan Sadikin Model)
 Antimicrobial Resistance (AMR)

Defined as micro-organisms that are not inhibited by

usually achievable systemic concentration of an
antimicrobial agent with normal dosage schedule and/or
fall in the minimum inhibitory concentration (MIC)
range.
 The History of Antimicrobial Resistance
(AMR). MRSA

Golden Age of Antibiotics

? PDR

Carbapenem
CRE resistance to Resistance MDR A.baumanii
Enterobacteriaceae MDR P.aeruginosa
26th antibiotics in US
(CRE) FOAR Study,2017.
 Mechanism Antibiotic Resistance.
Antibiotic Resistance

[Phenotypic/
Intrinsic (Natural) Acquired Culture Result (S,R,I)]

Genetic Methods

Chromosomal Methods Extra chromosomal Methods

Mutations Plasmids

(Genotypic/Bio-molecular)
IDSA.2004.
 Factors Contributing for AMR
Patient movement
within and
Livestocks between medical
and institutions Inappropriate
foodstuffs ness of use

Socioeconomic Infection control

factors measures

Antibiotic use Antibiotic resistance

Poor Dose/duration
adherence of treatment

Over- Non-antibiotic
Gene
prescribing transfer selection
 Risk factors associated with Carbapenem-Resistant Enterobacteriaceae
(CRE) infection.

vard, T. M. Perl .Combating the spread of carbapenemases in Enterobacteriaceae: a battle that infection prevention should not lose. Clin Microbiol Infect 2014; 20: 854–861.
 Why AMR is a concern
• Resistant organisms lead to treatment failure
• Increased mortality
• Resistant bacteria may spread in Community
• Low level resistance can go undetected
• Added burden on healthcare costs
• Threatens to return to pre-antibiotic era
• Selection pressure
BAD BUG in Internal Medicine Dept.
Dr. Hasan Sadikin Hospital,2012
103

257

761
Super Bug Etiology in Sepsis Patient, MIC Room
RSUP Dr. Hasan Sadikin, 2013

Super Bug Enterobacteriaceae

Fermenters (44.2%), Non Fermenters (25%)

MDRO Coccus (19.1%) and Fungal (1.97%)

 SNARS, Indonesia National Standard Hospital Accreditation, 2017.
PROGRAM NASIONAL
1. Menurunkan angka kematian ibu dan bayi serta meningkatkan angka kesehatan ibu dan bayi
2. Menurunkan angka kesakitan HIV/AIDS
3. Menurunkan angka kesakitan tuberkulosis
4. Pengendalian resistensi antimikroba (PRA/ARC)
5. Pelayanan geriatri

Elemen Penilaian Standar 4

1. Ada regulasi dan program tentang pengendalian resistensi antimikroba di
rumah sakit sesuai peraturan perundang-undangan.(R)
2. Ada bukti pimpinan rumah sakit terlibat dalam menyusun program. (D,W)
3. Ada bukti dukungan anggaran operasional, kesekretariatan, sarana
prasarana untuk menunjang kegiatan fungsi, dan tugas organisasi PRA.
(D,O,W)
4. Ada bukti pelaksanaan pengendalian penggunaan antibiotik terapi dan
profilaksis pembedahan pada seluruh proses asuhan pasien.(D,O,W)
5. Direktur melaporkan kegiatan PPRA secara berkala kepada KPRA.(D,W)
 ASP in JCI 6ed
Medication Management and Use (MMU), 2017.
MMU.1.1 The hospital develops and implements a program for the prudent
use of antibiotics based on the principle of antibiotic stewardship.

V
X
X
X
X
X
V
V
V
 Antimicrobial Stewardship Program (ASP)

• Antimicrobial Stewardship Programs (ASPs) are useful for

combating antimicrobial resistance and decreasing the spread of
resistant infections.
• Outline national initiatives that are directly influencing the role of
ASPs.
• Provide specific examples of the bundled approach to ASPs.
• Recommend clinical interventions for ASPs that can be
• implemented in various pharmacy practice models.

CDC. 2016
 Antimicrobial Stewardship Program (ASP) pada
Fasilitas Pelayanan Kesehatan

Strategi Utama Strategi Pendukung

1 3

4
2 6

PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 2406/MENKES/PER/XII/2011

Indonesia NAP on Antimicrobial Resistance

WHO, 2017.
 Action Plan of AMR in RSUP Dr. Hasan Sadikin.
1. KEPUTUSAN DIREKTUR UTAMA RUMAH SAKIT UMUM PUSAT
(RSUP) DR. HASAN SADIKIN BANDUNG NOMOR: HK.02.04/
E013/4520/III/2017 TENTANG PROGRAM PENATALAYANAN
ANTIMIKROBA (Antimicrobial Stewardship Programe) RSUP
DR. HASAN SADIKIN BANDUNG.
2. KEPUTUSAN DIREKTUR UTAMA RUMAH SAKIT UMUM PUSAT
(RSUP) DR. HASAN SADIKIN BANDUNG NOMOR: HK.02.04/
E013/4904/III/2017 TENTANG PANDUAN PENGGUNAAN
ANTIMIKROBA DI RSUP DR. HASAN SADIKIN BANDUNG.
3. SPO RESTRIKSI DAN PREOTORISASI, HS.1.B47.10.OOO40, 2015.
4. SPO KATAGORI ANTIMIKROBA UNTUK TERAPI EMPIRIS DAN
DEFINITIF ANTIMIKROBIAL, HS1.B47.10.00070, 2017.
5. SPO AUDIT PROSPEKTIF PEMAKAIAN ANTIMIKROBA, HS.1.847.
10.00041, 2017.
 Renew ASP/PPA Model RSUP Dr. Hasan Sadikin.
Perubahan/Pemilihan Antimikroba
Optimasi Dosis (Terapi Definitif, 7-14 hari)
Antimicrobial stewardship Team
Strategi Utama II Konversi Antimikroba
Audit Prospektif, Intervensi & IV-PO
Umpan Balik Edukasi (Streamlining)
(“Back End”)

Permintaan Antimikroba
(Terapi Empirik, 72 Jam,
PPA/ASP
Automatic Stop Order, de RSUP Optimal Outcomes
eskalasi) RSHS

Strategi Utama I
IT
Restriksi, Preotorisasi pada
Surveilans &
Formularium RSUP
Umpan Balik
Dr. Hasan Sadikin
(“Front End”)
“Optimal
Outcomes”

“Optimal outcomes”: achievement of cure, avoidance of toxicity, adverse effects and in the larger population
(avoidance of emergence or propagation of antimicrobial resistance).

Greater New York Hospital Association United Hospital Fund, 2011.

Chung GW et al. Virulence 2013; 4:1-7.
Restriksi dan Preotorisasi Antimikroba RSUP dr.Hasan Sadikin

Kategori I Kategori II Kategori III

Aminopenisilin Cepalosporin generasi 3 dan 4 Vancomisin
Penisillin Cepalosporin Teicoplanin
Cepalosporin (Gen.1 dan Antipseudomonas Linezolid
2) Fluorokuinolon Tigecycline
Khlorampenikol Antipeseudomonas Carbapenem
Asam Fusidat Flukonazol Aminoglykosida
Linkosamid Fosfomycin Fluorokuinolon
Makrolida Acyclovir (Gen.4)
Metronidazole Pirimetamin Piptazo
Fluorokuinolon (Gen.1 Colistin
dan 2) Variconazole
Tetrasiklin Mycafungin
Trimetoprim- Anidulafungin
sulfametoksasol Gancyclovir
Nitrofurantoin
Albendazole
Mupirosin
Kategori III, adalah antimikroba yang membutuhkan persetujuan sebelum antimikroba tersebut
Sulfadiazinboleh diresepkan. Persejutuan diberikan oleh konsultan spesifik di SMF jika telah
memenuhi kriteria.
Kategori II, adalah antimikroba yang hanya boleh diresepkan atas indikasi spesifik yang
kemudian ditinjau oleh Tim PPRA dalam kurun waktu 3 hari kerja.
PPA, , 2016
 Antimicrobial Stewardship Team RSUP dr Hasan Sadikin Model
(Multidisciplinary Team Approach in ASP to Optimizing Clinical Outcomes)*

Director/Chief
Medical Officer P&T
Information (CMO) Committee
Technology (TFT)
Infection Medical
Prevention Information
(PPI) ASP
ARCP
Systems
Coordinators
RSUP Leader
dr Hasan Sadikin
(Qualitative,Quantitative,
Infectious Resistance,Education)
Diseases Nursing Care

Microbiology Clinical Partners in Optimizing

Laboratory Pharmacy ASP~Dept./SMF
Specialists

Decentralized
Pharmacy
Specialist
*based on local resources Modified from : Dellit TH et al. Clin lnfect Dis. 2007;44:159-177.
PPA/ASP. RSUP dr Hasan Sadikin Bandung. 2016
 Blood Cultures Result in Sepsis Patients, Pre and Post PPA
[Pra PPA Januari-Maret (n=55), Post PPA April-Juli 2016 (n=57) di 4 Ruang Intermediate dan 1 Intensive]

Pre PPA Post PPA

Bacterial Pathogen
(n=55) (n=57)
Escherichia coli (ESBL) 2(3,6) 1(1,7)
Staphylococcus haemolyticus (MRCONS) 1(1,8) 2(3,5)
Staphylococcus epidermidis (MRCONS) 0(0) 2(3,5)
Pseudomonas aeruginosa (MDR) 1(1,8) 1(1,7))
Acinetobacter baumannii (MDR) 0(0) 1(1,7)
Aerococcus viridans (MDR) 1(1,8) 0(0)
Burkholderia cepacia (MDR) 1(1,8) 0(0)
Chryseobacterium gleum (MDR) 1(1,8) 0(0)
Enterococcus faecalis (wild type) 0(0) 1(1,7)
Kocuria rosea (MDR) 1(1,8) 0(0)
Sphingomonas paucimobilis (MDR) 1(1,8) 0(0)
Staphylococcus Iugdunensis (wild type) 1(1,8) 0(0)
Staphylococcus hominis (MRCONS) 0(0) 1(1,7)

Blood Cultures Result 10(18) 9(15,5)

Cultures (-) 45(81,8) 48(84,2)

A Felani, U Sumardi, I Parwati. The Difference of Defined Daily Doses and Cost of Ceftriaxone Therapy Before and After Antimicrobial Stewardship Programmed In
Critically Ill Patients. Thesis 2016.
 Conclusions

• AMR is the main problem for antibiotic treatment.

• AMU with ASP
• ASP is the solution for Combating Resistant Antibiotic Bacterial.
Review PPA/ASP RSUP dr. Hasan Sadikin Model by Amsterdam
University Hospital ASP Team

Thank You