Antimicrobial resistance:

How and Why

Kuntaman
Department of Microbiology
Faculty of Medicine - Dr. Soetomo Hospital
Universitas Airlangga -Surabaya
Komite PPRA Kementerian Kesehatan R.I.

What Resistance:
Standard dose

Fail to tackle Inf. Dis

Interaction: AB M.O.  Host

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 Case-1: What Resistance:

Clin-Lab Clin-Lab
T: 38.5 C T: 37.5 C
Leu: 17.000 Leu: 12.000
K.pneu-ESBL K.pneu-ESBL
AK AK

Interaction: AB M.O.  Host

What Resistance:

Clin-Lab Clin-Lab
Selection Pressure
T: 38.5 C  T: 37.5 C
Induce ResLeu: 17.000 Leu: 12.000
Sen  ResK.pneu-ESBL K.pneu-ESBL
How it develop
AK to res AK

Interaction: AB M.O.  Host

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What Resistance:
Ab: ??

K pneu
ESBL
E coli
Carb Res
Pse aeru
Pan-Res
Aciba

Ab-gram

What Resistance:

MEM
AK MDRO
LEV

HW Spread

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Res:  Change of bacterial receptor to AB

Beta-lactam
Erythromycin

Res:  Change of bacterial receptor to AB

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Cip
Lev
Mox

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 Cip
Lev
Mox

Mutasi  perubahan target

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 ALTERED OF A.M. TARGET SITE

QUINOLON BIND TO REPLICATION

GYRASE ENZYME
NOVOBIOCIN STOP

ALTERED CELL KILLED

GyrA/B MUTATION
CELL GROWTH

Kuntaman, Lab Mikro FK Unair/RSUD

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Dr.Soetomo Sby

ß-Lactamases
Mode of Action
S
Penicillin (Active)
N
O
ß-lactamase

N Penicilloate (Inactive)
O

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Cell wall impermeable

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AMX  AMX …P

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CTX  CTX …CRO……CAZ

MEM  MEM …Ceph-3,2,1, AMX ??

Others …

Jangan mudah pakai MEM

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 Terapi Empirik:
1. AB yang paling kuat: ???  Antibiogram:?
2. Dosis setinggi mungkin: ??
 Siapa yang menentukan AB terkuat
untuk infeksi tertentu: ??
 Dan Bgmn memilih: ??
3. Hanya antibiogram  belum cukup: ??

Without direct consultation,

recommendation are followed in 39%
cases
– Because the clinician will not change based
on a report alone

Diagn. Micro.Infect.Dis, 91;14:157-66

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 CASE-1
Day-2:
- GNR-Non Lact F
- Result AST
- ID

AST:
• Res: MEM, SAM, FOX, AMC, TZP
• Inter: SCF, CRO
• Sen: SXT, FEP, C, AK, LEV, CN, ATM, FOS, CAZ

CASE-2: SBE
• Male, 18 y.o.; Adm. To DSHS
• SBE & Shock Septic
• Temp. 39 C
• Leucocyte: 16.940/dl
• Blood Culture  Lab Micro:
• Staph hominis
• Sens: AMC, ERY, SXT, MEM, PTZ
Sering: MEM diberikan hanya o.k. Septic Shock: ?????

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 CASE-2
Day-7: Preparation for Cardiac surgery
• Temp. 37 C to repair valve
• Leucocyte: Protocol for AB Prophylaxis: ??
10.600/dl
• AB: Stop
• USG: Vegetation in
Mitral valve
• Blood Culture D/S:
No growth

Resistance: ??
• Bakteri
• Klinis
• Lingkungan

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 Kasus Sulit:
1. Pemeriksaan Mikrobiologi
2. Pelayanan Mikrobiologi Klinik
• kerjasama: AB Prudent vs Good outcome
Non-Prudent Less Res
Save Money
• Interpretasi lebih terarah
Save environt
• Patient Savety
• Ther empirik

NOVEL APPROACH for

Management of VAP 3
 Direct contact with Clin Microbiologist
(since 1st day of VAP identified):
- Can Improve Interpretation of Micro-
culture & definitive therapy for mostly
cases (Dr Soetomo Hosp)
Without direct consultation, recommendation are
followed in 39% cases (61% Lost)
– Because the clinician will not change based on
a report alone
Diagn. Micro.Infect.Dis, 91;14:157-66

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 Problem penanganan Penyakit Infeksi

• Bukan hanya diketahuinya bakteri

penyebab
• Tapi: para klinisi pemegang
pasien perlu memahami:
bagimana infeksi terjadi, sumber
nya apa, bgm cara
menangananinya.

• Indikator: Jika banyak MEM dipakai empiric: ????

SUMMARY
1. Resisten selalu muncul di setiap terapi AB
2. Setiap resisten akan terjadi perubahan target antibiotic
3. Tidak ada antibiotika tanpa disertai resisten.
4. Penggunaan AB paling kuat, akan meningkatkan resisten
AB golongan dibawahnya Gyssen
5. Beratnya penyakit, hanya salah satu pertimbangan
menggunakan AB paling kuat, bukan indikasi penggunaan
AB paling kuat

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 The strengthening of clin mcrob services, is absolutely
needed for improving the quality of health services, especially
in Inf Dis.

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