HARI

PARATON
KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA
KEMENTERIAN KESEHATAN R.I

MENGAPA PERLU ANTIBIOTIK PROFILAKSIS
dokter takut kalauterjadi IDO
beban perasaan dokter
reputasi dokter
pasien menderita
beban biaya

dokter ikut pengalaman yang lalu

operasi = prolaksis
pelajaran saat PPDS I
ikut seniornya

Pasien meminta An8io8k

STANDARISASI AB PROFILAKSIS

?
PREVALENSI TERJADI IDO
 kolonisasi

An8bio8ka prolaksis
Definisi Antibiotik profilaksis:
Antibiotik yang diberikan sebelum-saat-setelah operasi
pada kasus yang secara klinis tidak terdapat tanda infeksi.
Tujuannya untuk mencegah terjadinya ILO / SSI / IDO dan
mencegah kolonisasi

Golongan operasi
Bersih
Bersih terkontaminasi
PROFILAKSIS DOSIS TUNGGAL V/S MULTIPEL

Fakta Tidak ada
laporan perbedaan
signifikan

Single-dose versus multiple-dose antibiotic prophylaxis for the surgical treatment of

closed fractures .
Slobogean.et.al. Acta Orthopaedica 2010; 81 (2): 256262
Results: A total of 540 patients were recruited; (females73.7% of total ). The performed
surgical procedures were 547. The rate of wound infection was 10.9%. Multivariable
logistic analysis showed that; ASA score > 3; (p= <0.001), wound class (p= 0.001), and
laparoscopic surgical technique; (p= 0.002) were significantly associated with prevalence
of wound infection. Surgical prophylaxis was unnecessarily given to 311 (97.5%) of 319
patients for whom it was not recommended. Prophylaxis was recommended for 221
patients; of them 218 (98.6 %) were given preoperative dose in the operating rooms.
Evaluation of prescriptions for those patients showed that; spectrum of antibiotic was
adequate for 160 (73.4%) patients, 143 (65.6%) were given accurate doses, only 4 (1.8%)
had the first preoperative dose/s in proper time window, and for 186 (85.3%) of them
prophylaxis was extended post-operatively. Only 36 (6.7%) prescriptions were found to be
complying with the stated criteria.
The rate of wound infection was high and
Conclusion:
prophylactic antibiotics were irrationally used. Multiple
interventions are needed to correct the situation.
Results: Perioperative antibiotic prophylaxis was appropriate in 18.1% of cases. The
multivariate logistic regression analysis showed that patients with hypoalbuminemia, with a clinical
infection, with a wound clean were more likely to receive an appropriate antibiotic prophylaxis.
Compared with patients with an American Society of Anesthesiologists (ASA) score 4, those with a
score of 2 were correlated with a 64% reduction in the odds of having an appropriate prophylaxis. The
appropriateness of the timing of prophylactic antibiotic administration was observed in 53.4% of the
procedures. Multivariate logistic regression model showed that such appropriateness was more
frequent in older patients, in those admitted in general surgery wards, in those not having been
underwent an endoscopic surgery, in those with a higher length of surgery, and in patients with ASA
The most common
score 1 when a score 4 was chosen as the reference category.
antibiotics used inappropriately were ceftazidime, sultamicillin,
levofloxacin, and teicoplanin.
Conclusions: Educational interventions are needed to improve
perioperative appropriate antibiotic prophylaxis.
 Profil pemberian antibiotik
RS Dr.Soetomo & Dr. Kariadi (AMRIN study 2005)

Hasil
kategori
Sby (%) Semg (%)
Tidak ada indikasi
terapi
76 53

Tidak ada indikasi

profilaksis
55 81
KEBIJAKAN RUMAH SAKIT

An@bio@k prolaksis diusulkan oleh Dep/SMF

ditetapkan oleh KFT dan Direktur Rumah sakit
An@bio@k prolaksis @dak digunakan untuk
keperluan terapi
Dilakukan monitoring evaluasi se@ap 2-3 tahun.
Persiapan pasien operasi
 SCREENING FOR ESBL COLONIZATION

Recommendation
The panel decided not to formulate a recommendation due to the lack of
evidence.

Rationale for the recommendation

The literature search did not identify any relevant studies comparing the
tailored modification of SAP for the prevention of SSI in areas with a high
prevalence of extended spectrum beta-lactamase (ESBL)-producing
Enterobacteriacae (including patients with rectal colonization of ESBL) to no
modification of standard antibiotic prophylaxis. Furthermore, no studies
comparing routine screening for ESBL (irrespective of ESBL prevalence prior
to surgery) with no screening that could inform a recommendation for this
question were identified.
(WHO 2015)
 IDO dan kadar Glukosa

8 Glucose control (200 mg/dl

6.7%

Deep Infec8on Rate, %

7
6 P=0.002
5
4
3
2.5%
1.3% 1.6%
2
1
0
100150 150200 200250 250300
Day 1 Blood Glucose (mg/dL)
Zerr KJ et al. Glucose control lowers the risk of wound infec7on in diabe7cs a9er open heart opera7ons, page 360.
Reprinted from The Annals of Thoracic Surgeons, Vol. 63.
 Elec@ve 200 CRS pa@ents
Surgical Control: Rou@ne intraopera@ve
thermal care
Procedures (mean temperature 34.7C)
Periopera@ve Treatment: Ac@ve warming
Normothermia (mean temperature 36.6C)

Incidence of SSI
Control 19% (18/96)
Warm Pa8ent Strategies:
Start with warm room
Use Bair Hugger
Treatment 6% (6/104);
Cool room for procedure P=0.009 cold pa@ents
Use 40o irriga@on
Warm room on closing had 3x infec@on
GOAL : >36oC (98.6oF) rate

Kurz A et al. N Engl J Med. 1996;334:12091215.

 Elec@ve
Surgical 500 CRS pa@ents
Procedures 80% or 30% inspired oxygen during
opera@on and for 2 hours post surgery
Supplemental
All pa@ents received prophylac@c
Oxygen
an@bio@cs

Results
Arterial and subcutaneous PO higher in 2
80% oxygen group
Lower incidence of SSIs with higher
Oxygen Strategy: supplemental oxygen (5.2% vs 11.2%;
Supplemental O2 P=0.01)
for 2hrs in RR
low O2 2x infec@on rate

Greif et al. N Engl J Med. 2000;342:161167.


Pencegahan Menjelang Operasi
infeksi
terkendali Tidak gelisah
Tidur cukup
R/ Sleep inducer
Pasien mandi bersih dengan sabun
sabun chlorhexidine bagi bedah
thorax / orthopedi + MRSA (+)
 Elec@ve
Surgical
Procedures
Hair Clipping hair just before case is best

Removal Hair Removal Infection Rate

Method
sore / kerok/shaving 5.2 - 8.8%
pagi / kerok 6.4 - 10%
sore / cukur 4 - 7.5%
pagi / cukur 1.8 - 3.2%

Alexander JW, et al. Arch Surg 1983; 118:347-352

ANTIBIOTIK PROFILAKSIS

Cephalosporin gen I II
Cephazolin (2 gr)
Cefuroxime 1.5 gr)
Pada kasus alergi Cefalosporin
Ampisilin sulbaktam (1 gr)
Amoksisilin as. Klavulanat (1 gr)
Gentamisin (5-8 mg/kg BB)
Pada kasus bedah digestif
Kombinasi Metronidazole ( 500 mg)
Pada kasus bedah saraf
Ceftriaxon (1 - 2 gr)

19
 Timing Insisi
6
5

4
SSI (%)

3
2

1
0
2 0 2 4 6 8 10

hours
Harbarth et al, Circula@on 2000
Classen et al. N Engl J Med 1992
 CARA PEMBERIAN
AB PROFILAKSIS

30-60 menit sebelum insisi

Intravenous driP
dilarutkan dalam 100 ml normal saline
Lama pemberian 15-30 menit
Dosis tunggal max 24 jam
Tidak perlu skin test ?
Ditentukan dokter pembedah
diberikan oleh staf anestesi


 SAAT OPERASI
ANTIBIOTIK PROFILAKSIS

An@bio@k boleh diulang

perdarahan >1000 ml
Lama op >2-3 jam
Jenis dan dosis yang sama
an@bio@k tambahan bisa diberikan apabila
terjadi komplikasi atau diagnosis tambahan
Abses
 ANAPHILAKSIS

Angka kejadian 0.0025 % (25/1.000.000) pada

pemberian gol. Penisilin
36 % diketahui allergy terhadap penisilin
64 % @dak ada riwayat allergy
(Clinical Medicine & Research Volume 8, Number 2:
80-81, 2010 Marsheld Clinic. Clinmedres.org)
 ANAPHILAKSIS

Reaksi silang anaphilaksis antara gol. Penisilin terhadap

cephalosphorin 10 %
Pasien dengan riwayat setelah mendapat gol. Penisilin
berisiko terjadi pada pemberian beta lactam (C)
Anaphylaxis
laryngeal oedema
Bronchospasm
Hypotension
local swelling
Urticaria , pruritic rash
(SIGN. antibiotic prophylaxis in Surgery . 2008.)
 PENELITIAN
PENGGUNAAN ANTIBIOTIKA PROFILAKSIS
di Dep/SMF. Obstetri Ginekologi RSUD. Dr. Soetomo. (AMRIN 2003- 2004)

Operasi Angka ILO

Histerektomi Sub Total 0/46

Histerektomi Total 1/277

 Kasus & Prosedure
An8bio8k
Evidence
Level
Odd.Rt

an@bio@k Sec@o Cesarea HR 1 0.41

prolaksis Histerektomi TAH / TVH R 1 0.17
Tonsilectomy NR 1
Luka pada wajah NR 1
Partus normal +
episiotomi NR 1

Strumecomy NR 1 -
Ca Mammae R 1
Appendectomy HR 1 0.58
Colorectal surgery HR 1
Hernia NR 1
TUR prostate HR 1
Arthroplasty HR 1
Pemasangan kateter NR 1
HINDARI IDO GUNAKAN ANTIBIOTIK
PROFILAKSIS SECARA BENAR.