Curriculum Vitae

Name : Lie Khie Chen

Birth : Jakarta
Graduates
MD : FKUI 1994
Internist : FKUI 2003
Consultant : FKUI 2006
PhD : FKUI 2014
Position:
Medical Staff Department of Internal Medicine
Division of Tropical Medicine and Infectious Diseases
Faculty of Medicine University of Indonesia
Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
Member of National Committee Antimicrobial Control Resistance
Program, Ministry of Health, Republic of Indonesia.
Chief of Antimicrobial Control Resistance Program
Department of Internal Medicine
Dr. Cipto Mengunkusumo Hospital, Jakarta.
General Secretary of Indonesian Society of Tropical Infectious
Diseases Consultant (ISTIC/PETRI)
 Infection in Diabetic
Patients
Khie Chen

Division of Tropical Medicine and Infectious Diseases

Department of Internal Medicine
Medical Faculty University of Indonesia
 Susceptible Host
n Susceptibile
(elderly, pregnancy)
n Immunocompromised
(cancer chemotherapy, immunosuppressive,
organ transplant, HIV)
n Comorbid
(diabetes mellitus, chronic kidney
diseases/dialysis, congestive heart failure,
cerebrovascular diseases)
n Organ dysfunction
(renal/liver dysfunction)
Increased risk of infections in diabetic patients
Increased risk of UTI in diabetic patients
Glucose Control Reduce Mortality in Septic Patients

Van den Berghe G - Clin Cornerstone - 01-JAN-2003; 5(2): 56-63

Increased risk of progression infection to sepsis
 Microvascular dysfuction in diabetic cause
impairment of blood perfusion to site of infections
 Immunity impairment in diabetic patients
n Dysregulation of nitric oxide production cause
vasoconstriction, attenuate the ability of phagocyte to
reach infection site
n Impariment of complement resceptor and Fcg
resceptor mediated phagocytosis
n Increasing of early proinflammatory cytokine
production TNFa, IL-1, IL-6 in turn cause of insulin
resistance
n Inhibition production of ROS lead to impairment of
killing function of phagocyte
n Impariment of adaptive immunity (T cell function) in
poorly control diabetic
 Common cause of infection in
Diabetic patients
n Urinary tract infections
n Complicated skin and soft tissue infections : cellulitis,
necrotizing fasciitis and Fourniers gangrene
n Diabetic foot infections
n Respiratory tract infections : pneumonia, tuberculosis
n Fungal infections: Candidiasis, mucormycosis
n Malignant external otitis
n Cholecystitis
n Nosocomial or hospital acquired infections
 Urinary tract infections
n Asymptomatic bacteriuria
n Cystitis
n Pyelonephritis
n Urosepsis
n Catether related UTI
 Urinary tract infections in diabetic

n Contributing factors related : elderly, post menopausal

women, bladder dysfunction due to neuropathy, poor
glucose control and bacterial colonization
n Asymptomatic patients : no proven that antibiotic
treatment give benefit except in patient underwent
urinary tract operating procedure or pregnant women
n Early treatment symptomatic patient with appropriate
antibiotics : uncomplicated 5-7 days, complicated 10-14
days
n Aware of potential complication : pyelonephritis,
perinephric abscess, urosepsis
Antimicrobial Choice for Uncomplicated UTI

n Uncomplicated cystitis n Uncomplicated PN

Fosfomycin trometamol Ciprofloxacin
Ciprofloxacin Levofloxacin
Levofloxacin Cepodoxime proxetil
Ofloxacin Ceftibuten
Nitrofurantoin
TMP-SMX
Cepodoxime proxetil
Amoxclav
Cefixime
Antibiotic for complicated UTI
Community acquired Hospital acquired
Fluoroquinolone Cefepime
3rd generation Piperacillin tazobactam
cephalosporin Carbapenem
Betalactamase Aminoglycoside
inhibitors : Ampi- Vancomysin (MRSA)
sulbactam,
Cefoperazone
sulbactam
Diabetic foot infections
n Paronychia
n Cellulitis
n Ulcus
n Abscess
n Necrotizing fascitis
 Contributing factors in
diabetic foot infections
n Infections
n Neuropathy
n Peripheral vascular disorder
n Hyperglycemia
n Immunity impairment
Case cSSTI :Septic flebitis
Pola Mikroba pada Infeksi Kulit dan
Jaringan lunak di Jakarta 2009
Kultur steril 9
E.coli 5
Pseudomonas aeruginosa 13
Pantoea agglomerans 2
jenis kuman

Klebsiella pneumoniae 9
Enterobacter aerogenes 4
Acinetobacter anitratus 3
Proteus spp 19
Streptococcus spp 8
S.epidermidis 8
S.aureus 22

- 5 10 15 20 25
jumlah kuman

Irwanto 2009
 Management
n Source control : wound care,
necrotomy, amputation
n Adequate antimicrobial treatment
Ampi-sulbactam, Amox
2nd gen cephalosporin
Clindamycin
Ciprofloxacin, Moxifloxacin
Piperacillin tazobactam
Carbapenem
Vancomycin/Linezolide
(MRSA suspected)
n Supportive treatment :
Nutrition
Glucose control : insulin
Vascular and coagulation
management
n Adjunctive therapy
Hyperbaric
Immune modulator
Respiratory tract infections
Case : Severe infection in Diabetic

n Male 74 years old admitted in

ICU
n Severe pneumonia with
pleural effusion
n History of Diabetes mellitus,
CVD, COPD
Discharge from hospital in 3
months. Long term care at
home.
 Assessment and Planning
n Severe pneumonia in high risk patient (elderly, diabetic
underlying condition)
n Pathogen : community acquired infection OR
(hospital acquired infection still possible :
recent admission)
n Pathogen should be covered :
Klebsiella pneumonia (include ESBL)
Pseudomonas aeruginosa
Acinetobacter baumanii
n Antibiotic choice : Carbapenem/Pip-tazo/Ceph4th gen
+ Aminoglycoside/FQ
(De-escalation strategy)
Factors in Antimicrobials Selection

n Spectrum
n Tissue Penetration
n Antibiotic resistance
n Safety profile
n Cost
 Strategy for empirical treatment
Patient

Outpatient Hospitalized

Stable condition Severe or high risk

Escalation Deescalation

Antibiotic selection based on

Susceptibility and resistance pattern
Immunity status, co morbidity and organ dysfunction

Antibiotic monotherapy or combination

Pohan HT, 2005

 De-escalation approach to antimicrobial utilization
Serious hospital acquired infection suspected

Obtain appropriate microbial

sample for culture and special stain

Begin empirical antibacterial treatment with

a combination agents targeting the most common
pathogen based on local data

Follow clinical parameter : Temp, WBC, CXR

PaO2/FiO2, haemodynamic, organ function

De-escalating antibacterial based on

results of clinical microbiology data

Search for superinfection

Abscess formation
Non infectious caused
of fever
N Significant clinical improvement
after 48-96 hours
Y
Discontinue antibacterial after 7-14 days course based
on site of infection and clinical response

Kollef, Drugs 2003;63 (20): 2157

 Conclusions
n Diabetic consider as susceptible host to infection
n Diabetic patients :
micro vascular dysfunction
neuropathy
impair immune system
n Approaching to manage infection:
Site infections : Related to suspected pathogen
Severity and progressivity
n Antibiotic treatment :
Empirical : escalate or deescalate
Definite : choose antibiotic base on culure results
and drug of choice for specific pathogen