prudently

and Antibiotic
Stewardship

HENDRO WAHJONO

SMF MIKROBIOLOGI KLINIK

RSUP DR KARIADI
2016

Contents of this presentation

Antibiotic resistance a patient safety
issue
Situation in Indonesia
Drivers of antibiotic resistance
Consequences of antibiotic
resistance
Why inappropriate use of antibiotics
contributes to antibiotic resistance
the why
How prudent use of antibiotics can be
promoted in hospitals the how
Optimize Clinical Outcomes through appropriate

WHO World Health

Day
World Health
Day is
celebrated
every year on
7 April, under
the
sponsorship of
the World
Health

Dr.T.V.Rao MD

WAR AGAINST MICROBES

The art of war is deception; that is deceiving the
enemy. But in the war against microbes we have
deceived ourselves by misusing, under-using and
overusing antibiotics

How do you determine which

antibiotic to use?
Confirm presence of infection
Identify the pathogen
...Microbiology Lab.
Selective empiric therapy based on
host
and drug factors

AIM INDIA, 2003

Recommendations for Empirical Therapy
Know your Patient
Know your Drug
Know your Environment
Know your Limitations

Role of the Microbiologist

Provide an excellent database of the prevalence &
susceptibility profiles of microorganisms in the
Community, Hospital & ICU
Be part of the ICU team
Outcome of the First Summit Meetings , 2003

!
Q. Whats the most expensive
NEW antibiotics ?

A. The one that doesnt

work!

Think before Prescribing an antibiotic

Is an antibiotic necessary ?
What is the most appropriate
antibiotic ?
What dose, frequency, route and
duration ?
Is the treatment effective ?
Dr.T.V.Rao MD

Dosing is Important
Concentration dependant
Cmax = Peak

Cmax / MIC

AUC / MIC

Aminoglycosides
Fluoroquinolones

Aminoglycosides
Fluoroquinolones
Linezolid
Daptomycin
Tetracyclines

Concentration
Time
dependant

MIC
T > MIC

Penicillins
Cephalosporins
Carbapenems
Macrolides
Vancomycin
Clindamycin

Cmin = Trough

How To Choose Antibiotic(s)?

PATIENT
age
immunity
previous ATB

PK/PD

Epidemiology

Infection
Type
MICROORGANISM

Local Resistance

BIOLOGICAL
RESPONSE
MODIFIERS

ANTIBIOTICS
+
IMUNOMODULATO
R

FACTORS OF IN VIVO EFFECT

1. ANTIBACTERIAL
ACTIVITY

2. PHARMACOKINETICS
- HIGH
CONCENTRATION
IN BLOOD
- HIGH PENETRATION
TO
TISSUES

ANTIBIOTIC
CONCENTRATION
IN TISSUES

TREATMENT OF
INFECTION

3. COOPERATIVE ACTIVITY
WITH HOST DEFENCE
MECHANISM
- COOPERATIVE ACTIVITY
WITH PHAGOCYTES AND
COMPLEMENTS

1.
2.
3.

MIC
1.
2.
3.

TIME

What is Antimicrobial
Stewardship
An interdisciplinary team dedicated
to practices that improve
appropriate selection, dosing, route,
and duration of antimicrobial therapy
The ultimate goal of antimicrobial
stewardship is to improve patient
care and health care outcomes

Antibiotic Stewardship

Definition: A system of informatics, data

collection, personnel, and
policy/procedures which promotes the
optimal selection, dosing, and duration of
therapy for antimicrobial agents throughout
the course of their use
Purpose:
Limit inappropriate and excessive
antibiotic use
Improve and optimize therapy and
clinical outcomesOhl
for
individual
CA.the
Seminar
Infect Control 2001;1:210infected patient 21.
Ohl CA, Luther VP. J. Hosp. Med. 2011;6:S4

Antibiotic Stewardship

Is pertinent to inpatient, outpatient, and

long-term care settings
Is practiced at the
Level of the patient
Level of a health-care facility or system, or
network

Should be a core function of the medical

staff
(i.e. doctors and other healthcare
providers)
Utilizes the expertise and experience of
clinical pharmacists, microbiologists,
infection control practitioners and

Antimicrobial Stewardship
Team
Infectious Disease
Physician
Clinical Pharmacist
Clinical
microbiologist
Information System
Specialist
Infection control
professional
Hospital
epidemiologist
Leadership support

CID 2007; 44 (159-77

Early Appropriate Antibiotics and

Source Control
Gram positive organisms have
surpassed gram negatives as the
most common source of sepsis
Therapy targeted to the suspected
site (eg, CAP, intra-abdominal
source)
Drainage, debridement and device
removal as indicated

Resistance equation
Risk of emergence antibiotic resistance

Antibiotic pressure

genetic selection

Risk of
cross infection

Conversion from parenteral to oral therapy

Having a systematic
plan for switching from
parenteral to oral
treatment may have
an added benefit of
aiding in early hospital
discharge planning
Development of
clinical criteria and
guidelines allowing
conversion can
facilitate
implementation.

Some Health-Care Associated

Infections that May Occur
UTI associated with Foley catheters
Lower respiratory tract infection
(post-op and ventilator dependent)
Skin necrosis (skin breakdown)
Blood stream infection (and line
associated)
Surgical-site infection
Nutrition-related and malnutrition

Therapy Across the Sepsis Continuum

SIRS

Sepsis

Severe
Sepsis

Drainage
Debrideme
nt
Device
removal

Septic
Shock
62
%

28
%

Definitive
control

resection Antibiotics and Source Control

Chest
2000;118(1):146
Chest 1992;101:1644.

Therapy Across the Sepsis Continuum

SIRS

Sepsis

Severe
Sepsis

Septic
Shock

Early
Goal Directed Therap
*

Antibiotics and Source Control

Early Goal-Directed Therapy (EGDT): involves adjustments of
cardiac preload, afterload, and contractility to balance O2 delivery
with O2 demand
Chest 1992;101:1644.

Therapy Across the Sepsis Continuum

SIRS

Sepsis

Severe
Sepsis

Septic
Shock

Early Goal Directed Therap

Antibiotics and Source Control

* Insulin and tight glucose control

Chest 1992;101:1644.

Glucose Control:
Mechanisms
Stress hyperglycemia is common in
sepsis
Glucose has pro-inflammatory effects
Insulin resistance is common in
sepsis
Insulin has an anti-inflammatory
effect..
Benefit is likely related to both insulin
itself and lowering of blood glucose

Why prepare an
antibiogram?

Fits into several national guidelines

CDC 12-step
IDSA guidelines on antimicrobial stewardship
(2007)
CDC/HICPAC Management of multi-drug
resistant organisms in health care settings
(2006)

Part of Joint Commissions standards

(IM.4/ IM.8)
The hospital collects and analyzes aggregate
data to support patient care and operations.

Better services from Microbiology

Departments.
Basic infrastructure
should be updated for
detection of MRSA and
ESBL producers.
Documentation of all
Opportunistic
infections. and Hospital
infection outbreaks
CLSI/NCCLS/CUMITECH?
EUCAST

Improving Reporting of Antimicrobial

Susceptibility Testing Results: the
Importance of Post Analytical
Analysis
Describe the importance
antimicrobial susceptibility testing
in term of handling spec.

Describe the interpretation

of susceptibility testing data and clin.manifest.
Describes the post analytical
errors associated with interpreting
susceptibility testing results
CLSI 2010

Tantangan dalam penanganan

Serious Infection

Surviving Sepsis Campaign

A global program to:
Reduce mortality rates
Improve standards of care
Secure adequate funding

6 Hour Resuscitation
Bundle
Early Identification
Early Antibiotics
and Cultures
Early Goal Directed
Therapy

MIND ME
M microbiology guides therapy wherever
possible
I indications should be evidence-based
N narrowest spectrum required
D dosage appropriate to the site and type
of
infection
M minimise duration of therapy
E ensure monotherapy in most situations

Interpretation:
Patient fails to respond to
antibiotics
Depressed immune system
Undrained abscess
Foreign bodies
Severe underlying disease
Misdiagnosis
Mixed infection
Superinfection

Collateral damage of antibiotic therapy

VRE

3rd generation
cephalosporins

ESBL Klebsiella
-lactam-resistant
Acinetobacter
C. difficile

Fluoroquinolones

MDR Pseudomonas
C. difficile

Song, Jae-Hoon; The Changing Face of Polymicrobial

Infections; presented at 24th ICC, Manila, June 4-,

Risk Factors

Extremes of age: <1 year or >65 years

Surgical/invasive procedures
Malnutrition
Use of broad-spectrum antibiotics
Chronic illness
DM
CRF
Hepatitis

Immunodeficiency disorders
Nicki Roderman, RN, MSN, CCRN

Risk Factors
Compromised Immune Status:
AIDS
Use of cytotoxic and
immunosuppressive agents
Alcoholism
Malignant neoplasms
Transplant

Increase in the number of drugresistant microorganisms

Nicki Roderman, RN, MSN, CCRN

Keys
Keys to success:
Timely communication and
feedback
Ongoing improvements
Data-driven approach
Regular communication of results

COLLABORATION!
Nicki Roderman, RN, MSN, CCRN

Should this patient get appropriate treatment?

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

Step 4: Access the experts

Infectious Diseases Expert

Resources
Infectious Diseases
Specialists

Healthcare
Epidemiologists
Clinical
Pharmacists

Infection Control
Professionals

Optimal
Patient Care
Clinical
Pharmacologists

Clinical
Microbiologists
Surgical Infection
Experts

Rapid diagnosis
Appropriate treatment

Microbiology Lab

Reliable
answers
Least possible
risk

Communication

Clinician

GOALS

1.Patient safety
2.Cost reduction
3.Antimicrobial resistance
control
Subkomite Farmasi dan Terapi
Pelayanan Farmasi Klinik
Tim Pengendalian Infeksi RS
Pelayanan Mikrobiologi Klinik

Working together creates Safe

Hospitals

Teach Hand Washing a Habit to

Everyone

Dr.T.V.Rao MD

43

Antibiotics save Lives

Save Antibiotics from Misuse

Dr.T.V.Rao MD

44

Document your Antibiotic Resistance

and Sensitivity Patterns with WHONET
WHONET is a free
software developed by
the WHO Collaborating
Centre for Surveillance
of Antimicrobial
Resistance for
laboratory-based
surveillance of
infectious diseases
and antimicrobial
resistance.
Dr.T.V.Rao MD

45

Global United Efforts Can

Reduce Antibiotic Misuse

Dr.T.V.Rao MD

46

CONCLUSION
According to appropriate use guidelines it is important to:

Use antibiotics only for bacterial infections

Better manage antimicrobial resistance it is critical

Use targeted antibiotics with appropriate-spectrum
of activity and dose
Improve compliance with antibiotic regimens
-

CDC Get Smart Program,

CONCLUSION
Discussed prescribing strategies & where to
access help / information
Resistant G(-) dan G(+) should be well
considered.
Reliable Clinical Microbiology data support
the decision
Antibiotic stewardship is important for
preserving existing antibiotics and

TERIMA KASIH