Antibiotic Usage in Children

HEALTHCARE-ASSOCIATED INFECTION
(HAIs):
Management & Prevention

Unit Kerja Koordinasi Infeksi dan Pediatri Tropis

 OUTLINE

 BACKGROUND
 DEFINITION: Healthcare-associated infections (HAIs)
 RISK FACTORS
 SITES OF HAIs
 IMPACT OF HAIs (caused by antibiotics resistance)
 MANAGEMENT AND PREVENTION
 SUMMARY
BACKGROUND
 Healthcare-Associated Infections (HAIs) :
istilah baru untuk infeksi nosokomial
 Insiden pada pasien anak cukup tinggi :
- usia: terutama neonatus
- perawatan intensif: NICU, PICU
- pasien imunokompromais dan hemato-onkologi
 Kuman penyebab seringkali sudah resisten
terhadap berbagai antibiotik
 TB
 MRSA,VRSA,VRE
 Clostridium difficile
 MDR Gram-negative
 Enterobacteriaceae (Escherichia coli and Klebsiella pneumoniae)
 Acinetobacter species
 Pseudomonas aeruginosa
 Incidence = 5-10%
 Incidence rising with time  next table
 ~2,000,000 patients develop a healthcare-
associated infection each year
 direct cause deaths ~90,000
 delays discharge
 Cost estimated at $4.5 to $5.7 billion dollars per
year
 Why do HAIs increase?

 Greater severity of illness of hospitalized patients

 More severely immunocompromised patients
 Newer devices and procedures in use
 Increased introduction of resistant organisms from the
community
 Ineffective infection control practices
 Increased of inappropriate antimicrobial prophylaxis
 Increased use of polymicrobial antimicrobial therapy,
especially in intensive care
DEFINITIONS
 Healthcare-associated infection:

An infection occurring in a patient during the process of

care in a hospital or other healthcare facility which was
not present or incubating at the time of admission.
(Cut-off point 48 hours)

This includes infections acquired in the hospital

but appearing after discharge,

and also occupational infections among staff

http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
 RANTAI PENULARAN PENYAKIT INFEKSI

Agen Penyebab Infeksi

Bakteri, Jamur, Virus,
Riketsia, Parasit

Pejamu Rentan: Reservoir:

Immunocompromised; Pasca bedah; Manusia; Air dan Larutan;
Luka bakar; Penyakit kronik;Umur
muda; Lansia
Peralatan

Tempat Masuk: Tempat Keluar:

Lapisan mukosa; Luka; Sal. Cerna; Sekret; Eksreta; Droplet
Sal. Kemih; Sal. nafas

Cara Penularan:
Kontak; (langsung, tak langsung,
droplet; melalui Udara; mel.
Benda; Vektor
RISK FACTORS OF HAIs
 Umur: neonatus >>
 Imunodefisiensi, penyakit kronis
 Interupsi barier anatomis:
 Kateter urin
 Prosedur operasi
 Intubasi pernafasan
 Kanula vena dan arteri
 Luka bakar dan trauma
 Implantasi benda asing:
 indwelling catheter
 surgical suture material
 cerebrospinal fluid shunts
 valvular / vascular prostheses

 Perubahan mikroflora normal:

 pemakaian antibiotik ???
SITES OF HAIs
CDC/NHSN Surveillance Definition of Healthcare-
Associated Infection and Criteria for Specific Types
of Infections in the Acute Care Setting, 2008

Urinary tract 40%

Lung 20%
Surgical site 17%
Bloodstream 8%
 HAIs: etiology by sites

CLA-BSI HAP CA-UTI SSI

Coagulase- P aeruginosa Escherichia coli S aureus (20%)

negative (22%) (19%)
staphylococci P aeruginosa
(38%) S aureus (17%) C albicans (14%) (15%)

Enterococcus Haemophilus P aeruginosa Coagulase-

(11%) influenzae (10%) (13%) negative
staphylococci
S aureus (9%) (14%)

Candida
albicans (5.5% )
THE ICEBERG EFFECT

INFECTED

COLONIZED
Weinstein RA. Am J Med 1991;91(suppl 3B):180S
 Where do the microbes come from?

• patient's own flora

• cross infection from medical personnel
• cross infection from patient to patient
• hospital environment- inanimate objects:
- air
- dust
- IV fluids & catheters
- washbowls
- bedpans
- endoscopes
- ventilators & respiratory equipment
- water, disinfectants etc
 THE INANIMATE ENVIRONMENT CAN
FACILITATE TRANSMISSION
X represents
VRE culture positive sites

~ Contaminated surfaces increase cross-transmission ~

The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment.
Hayden M, ICAAC, 2001, Chicago, IL
 MECHANISMS OF TRANSMISSION

 Contact:
 direct (person-person), indirect (transmission through
an intermediate object contaminated instruments)
 Common-vehicle:
 common animate vehicle as agent of transmission
(ingested food or water, blood products, IV fluids)
 Airborne:
 organisms that have a true airborne phase as pattern
of dissemination (TB, Varicella)
 Droplet:
 brief passage through the air when the source and
patient are in close proximity
 Modifiable Risk Factors

Characteristic Risk Factor Hierarchy

Insertion circumstances Emergency > elective

Skill of inserter General > specialized

Insertion site Femoral > subclavian

Skin antisepsis 70% alcohol, 10% povidone-iodine >

2% chlorhexidine
Catheter lumens Multi lumen > single lumen

Duration of catheter use Longer duration of use greater risk

Barrier precautions Submaximal > maximal

IMPACT OF HAIs:
CAUSE BY ANTIBIOTICS RESISTANCE
 Common spread of antibiotic-resistant
organisms in health care facilities

Pathway Risk Example

Introduction of a Admission of a patient with • Methicillin-resistant Staphylococcus aureus
resistant organism a resistant organism • Vancomycin-resistant Enterococcus
• Extended-spectrum β-lactamases E. coli
• Multidrug-resistant Acinetobacter
• Multidrug-resistant tuberculosis

Emergence of a new Selective pressure from • Extended-spectrum β-lactamases E.coli

resistant organism antimicrobial use • Gram-negative bacilli resistant to quinolone
(e.g., Enterobacter or Pseudomonas species)
• Gram-positive cocci resistant to quinolone
(e.g., Streptococcus pneumoniae)

Clonal dissemination • Inadequate hand • Methicillin-resistant S. aureus

hygiene • Vancomycin-resistant Enterococcus
• Insufficient use of barrier • Multidrug-resistant gram-negative bacilli
isolation • Clostridium difficile
• Inattention to
environmental
reservoirs or vectors
 Example:
EVOLUTION OF ANTIMICROBIAL RESISTANCE
IN GRAM-POSITIVE COCCI

Penicillin Methicillin

[1940s] [1960s] Methicillin-resistant

Penicillin-resistant
S. aureus S. aureus S. aureus (MRSA)
Vancomycin
[2002] Ciprofloxacin
Vancomycin- 1987
resistant
S. aureus Vancomycin Vancomycin-resistant
(glycopeptide) enterococcus (VRE)
intermediate-resistant
S. aureus
[1997]
 Methicillin Resistant S. aureus (MRSA)
 Colonisation common:
Nose Axilla Perineum
Wounds/Lesions

Spread by:
Hands
Fomites
Aerosols
Becoming more common in the
community

 May cause -
Wound infection
Bacteraemia
Skin/soft tissue infection
U.T.I.
Pneumonia etc.
 MRSA and pan resisten
RSCM 2013-2014

Bulan/ Jan –Juni Juli – Des Jan-Juni Juli-Des

tahun 2013 2013 2014 2014

Jenis kuman n %R n %R n %R n %
R

MRSA 44/181 24 31/205 15,1 46/244 18,9

23

Pan resisten 177 85 111 64

HAIs:
MANAGEMENT and PREVENTION
 CHALLENGES in MANAGEMENT
and PREVENTION of HAIs

 Changing population of hospital patients

 Increased severity of illness
 Increased numbers of immunocompromised patients
 Prolonged hospitalization
 More and larger intensive care units

 Lack of compliance with hand hygiene

 Reduced infection control resources nationwide

 Increased cost

 Higher mortality
 The role of Infection Control
as important as the Antibiotic Control

ESBL
MRSA VRE K. pneumoniae

Infection Antibiotic
Control Control
 SPECIFIC FACTORS
ASSOCIATED WITH HAIs DUE TO ANTIBIOTICS USAGE

 All resistance is local

 Hospital demographics
 Size
 Teaching versus non-teaching
 Location
 Care in an intensive care unit
 Duration of hospitalization and use of an
invasive medical device
 Prior antimicrobial use
Terapi bergantung kepada jenis infeksi
(tempat infeksi) dan etiologi (bakteri)
Penggunaan antibiotik secara judiciously:
~ peta kuman dan antibiogram
 Terapi simptomatik untuk syok, hipoventilasi
dan komplikasi lainnya
 Kadang diperlukan “source control” dengan
tindakan pembedahan atau pencabutan alat
 Bloodstream infections

 Pencabutan kateter i.v. harus dipertimbangkan

bila:
- sudah tidak diperlukan lagi
- infeksi disebabkan oleh S aureus atau Candida
- pasien tampak sakit berat/kritis
- bakteremia tidak dapat diatasi dalam 48-72 jam
- gejala infeksi menetap lebih dari 48-72 jam
- bila terdapat endokarditis atau thrombophlebitis
septik
 Bloodstream infections (lanjutan)

 Lamanya terapi antibiotik bergantung kepada:

- kuman penyebab berdasar biakan
- apakah kateter i.v. masih terpasang/tidak
- terdapat komplikasi/tidak (endokarditis, sepsis)

 Umumnya antibiotik diberikan selama 10-14 hari

setelah biakan darah negatif
 Pneumonia

Pemilihan terapi antibiotik empirik harus

mencakup untuk kuman “multidrug-
resistant “(MDR)
Belum ada konsensus tentang lamanya
pemberian antibiotik pada VAP
Pada umumnya lama pemberian 14-21
hari
Catheter-associated Urinary tract infection

 Bila memungkinkan kateter urin dicabut untuk

mencegah terjadinya ISK yang menetap atau berulang

 Pada umumnya lama pemberian antibiotik selama 10-14

hari, bila ISK disertai sepsis, pyelonephritis, atau bila ada
kelainan anatomis sistem saluran kemih
 Surgical Site Infections

Harus diatasi dengan kombinasi antara

tindakan/ perawatan bedah dan
pemberian antibiotik
Antibiotik segera disesuaikan apabila
telah keluar hasil biakan kuman
Bila infeksi berat seperti gangren dan
nekrosis jaringan (oleh kuman
streptokokus) harus segera dilakukan
tindakan pembedahan
 REMEMBER....:
PRECAUTION OF HAIs
 ISOLATION PRECAUTION
TRANSMISSION-BASED
STANDARD PRECAUTION PRECAUTIONS
Hand-hygiene
 Contact
Personal-protective-device
 VRE, MRSA, C difficile
Sharp and waste management
Patient placement/isolation/cohort
 Droplet
Environment
Linen management
 Pneumonia
Decontamination and sterilization
 Airborne
Health care worker
Lumbal puncture  TBC
Cough etiquette
Safety injection
 KEY INTERVENTIONS
IN INFECTION CONTROL
especially for resistant pathogens

Standard precaution+Transmission based

precautions (Isolation precautions)
Surveillance
 Many Personnel Don’t Realize When
They Have Germs on Their Hands

Healthcare workers can get 100s to 1000s of

bacteria on their hands by doing simple tasks
like:
 pulling patients up in bed
 taking a blood pressure or pulse
 touching a patient’s hand
 rolling patients over in bed
 touching the patient’s gown or bed sheets
 touching equipment like bedside rails, overbed tables, IV
pumps
HAIs: Summary
 Tatalaksana pemberian antibiotik

Kenali faktor risiko

Tentukan jenis infeksi
Tentukan kemungkinan etiologi tersering:
- usia
- tempat perawatan (ruang rawat/ICU)

Mempelajari peta kuman dan pola kepekaan

terhadap antibiotik di RS/fasilitas kesehatan
DATA POLA KUMAN
 ANTIBIOTIC RESISTANCE PROGRAM SYSTEM
IN RSCM

Panitia Farmasi dan

Terapi Clinical Microbiology

PPRA
(TEAM PPRA + Laporan
WORKING DIRECTOR
GROUP PPRA)

INFECTION CONTROL DEPT PHARMACOLOGY

COMMITTEE CLINIC
 PPRA team
(RSCM
since 2009) Quantitative

Antibiotic
evaluation

Qualitative
(Gyssens)

ANTIBIOTIC
EVALUATION
 Terapi empirik dengan antibiotik spektrum luas
 Selanjutnya terapi definitif disesuaikan dengan hasil
biakan kuman
 Pemilihan antibiotik harus berdasarkan hasil uji
kepekaan dan respons klinis
 Tentukan lama terapi yang optimal sesuai jenis
infeksi dan kuman penyebab

Gunakan pola/cara Gyssens

 AUDIT QUALITATIVE
Gyssens category
 I. Appropriate
 II. Inappropriate
a. dosage
b. interval
c. prescription
 III. Inappropriate
a. too long
b. too short
 IV. Inappropriate
a. there are antibiotics more effective
b. there are antibiotics less toxic / safer
c. there are antibiotics cheaper
d. there are antibiotics more specific (narrow spectrum)
 V. No indication
 VI. Medical record not complete
Gyssens IC. J.Antimicrob Chemother 1992;30:724-7
KEY INTERVENTIONS IN HAIs
by ANTIBIOTIC CONTROL

 Don’t treat non-bacterial infections or non-

infectious diseases with antibiotics
 Don’t prolong the duration of beyond what
is needed
 Avoid prophylactic antibiotics unless benefit
demonstrated
 Use the narrowest spectrum agent
available