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Antimicrobial Resistance Control Program
(ARCP) : implementing in
Dr. Cipto Mangunkusumo Hospital
Khie Chen
Antimicrobial Resistance Controlling Program
Department of Internal Medicine
Dr. Cipto Mangunkusumo Hospital
Jakarta
Current Problem in Antibiotics Use
Increasing Resistance Problems
Limited new antibiotics in pipelines
How to use antibiotics appropriately?
Infection Major pathogen Major
resistance
Urinary tract
infection
E. coli, K.
pneumoniae
Enterococci
ESBL
VRE
Pneumonia P. aeruginosa
A. baumanni
MDR/PDR/XD
R
Surgical site
infection S. aureus MRSA
Bloodstream
infection
Coagulase(-)
Staphylococci
S. aureus
MR-CNS,
MRSA
(UTI)
(Gastroenteritis)
Infectious diagnosis in Internal Medicine Ward Apr-Jun 2010
1. Establish national infection control programs :
National programs to control antimicrobial resistance (ARCP/PPRA) since 2005
2. Establish effective, hospital-based therapeutics committees for monitoring antimicrobial usage
3. Develop and regularly update on guidelines for antimicrobial usage, especially on treatment & prophylaxis
4. Ensure access to microbiology labs
(National Programe)
Dr. Cipto Mangunkusumo Hospital
National General Hospital
Teaching Hospital
Class : A
Owner : Ministry of Health – Indonesia
Address : Jl. Diponegoro No. 71, Jakarta
Number of bed : 1220
Department/unit : 32
Internal Medicine Department
Regular Bed 100
(Male 53, Female 47)
Bed in Isolation Ward
(for immunocompromised patient) 24
Bed for HIV/AIDS Patient 6
Bed in High Care Unit 4
Total 134
Divisions in Internal Medicine
Department
Metabolic and
Endocrinology
Kidney and Hypertension
Gastroenterology
Rheumatology
Medical Hematology and
Oncology
Psychosomatic
Tropical and infectious
Disease
Pulmonology
Geriatry
Clinical Allergy and
Immunology
Cardiology
Hepatology
Antimicrobial Resistance Controlling
Programe
Hospital policy of Antimicrobial Usage
Antimicrobial Resistance Controlling Programe
- Decreasing Antimicrobial Resistance
.
•
IDSA/SHEA. Guidelines for developing an instutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44: 159–77.
Aims
Decreasing total use of antibiotics (quantitative)
Increasing appropriate use of antimicrobial
(qualitative)
IDSA/SHEA. Guidelines for developing an instutional program to
enhance antimicrobial stewardship.. Clin Infect Dis 2007; 44: 159–77.
Nosoco
mial Infection
Committe
Pharmacist Clinical
Microbio logist
Clinical Pharmaco
logist
ARCP
Dept
Dept Dept
Dept
Dept Dept
Dept
Dept
Colaborative of ARCP
Decree of Director of CM Hosp:
7139/TU.K/34/VII/2009
deciding:
Formation of Antimicrobial Resistance
Controlling Program
(ARCP/PPRA)
Pharmacy and
Therapeutic
Committe
ARCP
Hospital and
Department
Team
Collaborative working system of
ARCP
Clinical Pharmacist Nosocomial Infection
Committe
Clinical
Microbiologist
Hospital Director REPORT
Working Task of ARCP Team
Deciding hospital regulation of antimicrobial resistance controling
Deciding policy of antimicrobial usage
Develop program of antimicrobial resistance controlling
Monitoring and evaluation of ARCP
Organizing discussion forum in managing infectious disease
(and antimicrobial usage auditing)
Socialization and education of appropriate antimicrobial usage for physician/users
Develop clinical researches related to ARCP
ARCP Team Internal Medicine Departement
Div Hepatology
Dr. Andri Sanityoso
Div Metabolic Endocrine
Dr. M. Yunir
Div Kindey Disesase and Hipertension
Dr. Pringodigdo
Div Gastroenterology
Dr. Marcell Simadibrata
Div Hematology& Clin Oncology
Dr. Ichwan Rinaldi
Div Rheumatology
Dr. Rudi Hidayat
Div Tropical Medicine &
Infectious Disease
Dr. Khie Chen, Dr. Erni J Nelwan
Div Pulmonology
Telly Kamelia
Div of Geriatri
Dr. Kuntjoro Harimurti
Div Allergy&Immunology
Dr. Evy Yunihastuti
Div Cardiology
Dr. Muhadi
Working Task of ARCP Internal Medicine
Develop Hospital Guidelines of antimicrobial usage
Perform socialization and education programe
Perform antimicrobial usage controlling programe in
Dept of Internal Medicine
Implementing antimicrobial auditing
Implementing antimicrobial surveillance
Developing Antimicrobial Usage Guidelines
Base on consensus
Existing national/international guidelines
Suggestion from the users, clinical microbiologist
Drug availability and cost
Practical guidelines and easy to perfom
Developing Antimicrobial Usage Guidelines
Make priority
a. Guidelines for antimicrobial prophylaxis
b. Guidelines for treatment
Most common infections in each department:
e.g. ICU : HAP/VAP
Internal Medicine : CAP, UTI, IAI, SSTI
Pediatric : URTI, LRTI, CNS infections
Surgery : Surgical prophylaxis, SSI
Hospital Antimicrobial
Guidelines Pattern/Stratification
1. Diseases Classification or stratification
e.g Pneumonia : CAP -- class I-IV
HAP – early onset : risk factor
-- late onset
2. Treatment approach : empirical
definite treatment
Guidelines Matrix example
Diagnos
is Diagnosis Terapi Empirik
Lama
terapi Mikroorganisme Terapi Definitif Dosis
Monoterapi Kombinasi
HAP
Cefuroxime
2x500 mg (oral) (cari
info injeksi 2x1 gr))
Pneumonia
Nosokomial (HAP)
early onset, tanpa
faktor risiko
(1) sefalosporin
generasi 2 (tanpa
antipseudomonas)
7 hari
Streptococcus
pneumonia Cefotaxime
1-2 gram setiap 8 jam
(2) sefalosporin
generasi 3 (tanpa
antipseudomonas)
Haemophilus
influenza Ceftriaxone
1-2 gram/hari
(maksimal 4
gram/hari)
(3) Fluoroquinolon
oral atau injeksi Klebsiella
pneumonia Ciprofloxacin (tunda)
3x400 mg (IV) 2x750
mg (oral)
Escherichia coli
Levofloxacin
1x750 mg (dapat
disesuaikan dengan
berat badan sekitar
1x500-750 mg) IV ;
1x750 mg (oral)
Enterobacter spp.
Moxifloxacin 400 mg/hari (IV) ;
400mg/hari(oral)
Proteus spp.
Ampicillin Sulbactam injeksi 3x1,5 gr
Serratia
marcescens Amoxiclav injeksi 3x1,5 gr
S.aureus (MSSA)
ARCP Socialization and Education
Clinical staff and clinical assistant meeting
Book/brochure and leaflets
Online : ppra-ilmupenyakitdalam.blogspot.com
Email : ppra-ipd@gmail.com
Portal akan memuat infomasi mengenai kebijakan dan Panduan serta antibiotik
yang digunakan dalam cycling dan mixing
Controlling of Antimicrobial Usage
Antibiotics in line I and II
Controlling base on antimicrobial hospital guidelines
Perfom antimicrobial cycling and mixing
Control by pharmacy
Pre authorization (approval): out of the guidelines
Antibiotics in line III
Need pre authorization
Empirical : critical condition and sepsis
Definite : base on microbiological culture results
Antimirobial groups classification
Line 1 Line 2 Line 3
Aminoglicoside
Penicillin
1st and 2nd gen Cef
Chloramphenicol
Fusidic acid
Lincosamide
Macrolide
Nitroimidazole
Fluroquinolone
1st and 2nd gen
Tetracyclien
TMP-SMX
Fosfomycin
3rd gen Cephalosporin
Fluroquinolone
gen 3rd and 4th
Amikacin
Teicoplanin3
Linezolide
Cefepime
Cefpirome
Carbapenem
Tygecycline
Ceftazidime
Pip-Tazo
Aztreonam
Vancomycin
Role of Microbiological Laboratory
Important to documented infections
Barier :
Lack of awareness the importance to collect
microbiological specimen before giving antibiotics.
Inappopriate procedure to collect the specimen.
Lack of knowledge interpreating the microbiological
results
If definite pathogen could be identified, narrow spectum antibiotic could be given.
Auditing
Periodically done by antibiotic team (multi
department), commissioned by management of
hospital
Audit of medical records, copy of prescriptions
Percentage of compliance to antibiotic guideline
Reward and punishment
Antibiotics auditing
Recording of antimicrobial usage
Quantitative audit : Pharmacy
Qualitative audit : Gyssen classification
Perform by ARCP Team, Clinical pharmacologist, clinical microbiologist
Evaluation of policy and antimicrobial guidelines
Feed back to physician/users
Yearly auditing report
Quanti tative audit
Defined Daily Dose (DDD): average dosage for adults
eg:
Tetracyline : 1 DDD = 1000 mg
Ampicillin : 1 DDD = 2000 mg
Amoxycillin : 1 DDD = 1000 mg
Ceftriaxone : 1 DDD = 2000 mg
Antimicrobial usage in hospital :
DDD/100 patient-days (bed-days)
Antimicrobial usage in community:
DDD/1000 person-days (inhabitant-days)
Evaluation category of
Antibiotics Usage by Gyssens
I. Correct Usage
II. Incorrect due to:
a) Incorrect dose b) Incorrect interval c) Incorrect route
III. Incorrect due to: a) duration too long b) duration too short
IV Incorrect due to: Alternative drug that is
a) more effective b) less toxic c) cheaper d) more specific
V No Indication
VI Medical record is insufficient to be
evaluated
Antimicrobial quantitative data in Dept of
Internal Medicine April-Jun 2010
Data Penelitian di Departemen IPD April-Juni
2010 tingkat konsumsi AB : 170 DDD/100 bed
days (Dina Fauzia, Dept Farmakologi FKUI)
Computer Base Programe
Implementation
Computer base antimicrobial prescription
Computer base antimicrobial used recording
Computer base auditing and surveilans
Lack of awareness from hospital
committee/management about the importance and
urgency to implementing ARCP
Lack of personnel willing to spare time and effort to
develop and enforcing ARCP
Lack knowledge of personel how to start and
implementing ARCP
Difficulties to implementing antibiotic restrictions in term
of reducing the users authority, and judgment
Lack to spare budget (no financial profit)
Improvement in clinical markers (such as
reduced length of stay).
.
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