PERAN STRATEGIS PPI

DALAM PPRA
PROF DR DR HINDRA IRAWAN SATARI, SPA(K), MTROPPAED
KETUA, PP PERDALIN
KETUA, POKJANAS PENCEGAHAN PENGENDALIAN INFEKSI, KEMKES RI
ANGGAUTA, KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA, KEMKES RI
AGENDA

Pendahuluan
PPRA
Peran strategis PPI dalam PPRA
Kesimpulan
 MASALAH KUNCI
TERKAIT PENINGKATAN
RESISTENSI
ANTIMROBA
AGENDA

Pendahuluan

PPRA
PPI
Kesimpulan
 Lima tujuan startegis Rencana Aksi Global Resistensi Anti Mikroba (PRA)
sebagai cetak biru penyusunan rencana aksi nasional

1: Improve awareness and understanding of AMR through effective communication,

education and training.
2: Strengthen the Reduce the incidence of infection knowledge and evidence base through
surveillance and research.
3: Through effective sanitation, hygiene and infection prevention measures.
4: Optimize the use of antimicrobial medicines in human and animal health.
5: Develop the economic case for sustainable investment that takes account of the needs of all
countries, and increase investment in new medicines, diagnostic tools, vaccines and other
interventions.
PERMENKO NO: 7 TAHUN
2021

RENCANA AKSI NASIONAL

PENGENDALIAN
RESISTENSI ANTIMIKROBA
2020-2024
 KepMenKes No
HKL.01.07/MENKES/6460/2021
TENTANG PEMBENTUKAN
KOMITE PENGENDALIAN RESISTENSI
ANTIMIKROBA
SUSUNAN KOMITE
PENGENDALIAN
RESISTENSI
ANTIMIKROBA
 Penatagunaan Antimikroba (PGA) sebagai
komponen integral sistem kesehatan

 AMS is one of three “pillars” of an

integrated approach to health systems
strengthening.
 The other two are:

 Infection prevention and control (IPC) a

 Medicine and patient safety.

KOMITMEN WHO SEARO DALAM PEMNDEKATAN MUTU,
KESELAMATAN PASIEN DAN PPI
BANGKOK, 12 OKTOBER 2022
 PRA dan Cakupan Kesehatan Semesta
(AMR and Universal health coverage)

 When applied in conjunction with antimicrobial use

surveillance, and the WHO essential medicines list
(EML) AWaRe16 classification (ACCESS, WATCH,
RESERVE), AMS helps to control AMR by
optimizing the use of antimicrobials.
 Linking all three pillars to other key components of
infection management and health systems
strengthening, such as AMR surveillance and
adequate supply of quality assured medicines,
promotes equitable and quality health care towards
the goal of achieving universal health coverage.
CAKUPAN KESEHATAN SEMESTA
 PROGRAM PENATAGUNAAN ANTIMIKROBA (PGA)
ANTIMICROBIAL STEWARDSHIP PROGRAMS (ASP)

Hospital based programs dedicated to improving

antibiotic use, commonly referred to as “Antimicrobial
Stewardship Programs” (ASPs), can both optimize the
treatment of infections and reduce adverse events
associated with antibiotic use.
 KOMPONEN INTI
PGA

• Leadership Commitment: Dedicating necessary human, financial and information technology

resources.
• Accountability: Appointing a single leader responsible for program outcomes. Experience with
successful programs show that a physician leader is effective.
• Drug Expertise: Appointing a single pharmacist leader responsible for working to improve
antibiotic use.
• Action: Implementing at least one recommended action, such as systemic evaluation of
ongoing treatment need after a set period of initial treatment (i.e. “antibiotic time out” after 48 hours).
• Tracking: Monitoring antibiotic prescribing and resistance patterns.
• Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses and
relevant staff.
• Education: Educating clinicians about resistance and optimal prescribing.
 DAFTAR TILIK ELEMEN KUNCI PROGRAM PRA

• DUKUNGAN PIMPINAN
• TERUKUR
• TENAGA AHLI
 DAFTAR TILIK ELEMEN KUNCI PROGRAM PRA

o Kebijakan
o Intervensi spesifik untuk meningkatkan
pemberian antibiotik
• Intervensi menyeluruh (Broad intervention)

• Intervensi oleh Farmasist

• Intervensi berdasar diagnosis dan infeksi

spesifik
 LACAK:
PEMANTAUAN, PERESEPAN, PENGGUNAAN DAN
RESISTENSI ANTIBIOTIK

• PROSES PENILAIAN
• PENILAIAN PENGGUNAAN ANTIBIOTIK DAN
HASIL PENGOBATAN
 Informasi bagi staf:
Pelaporan perbaikan penggunaan antibiotik dan
resistensi

• Umpan balik penggunaan antibiotik di

fasilitas spesifik?
• Antibiogram?
• Komunikasi pribadi secara langsung?
 KOMPONEN INTI PGA

1. Tingkatkan PPI
2. Kendalikan sumber infeksi
3. Resepkan antibiotik atas indikasi tepat
4. Dosis adekwat
5. Masa pemberian sesingkat mungkin berbasis bukti
6. Pertimbangkan pengobatan setelah biakan
diterima
7. Dukung surveilans PRA dan PPI serta pemantauan
konsumsi antibiotik
8. Edukasi staf
9. Dukung pendekatan interdisiplin
AGENDA

Pendahuluan
PPRA
Peranan strategis PPI dalam PPRA
Kesimpulan
 PERMENKES NO 27 TAHUN 2017
tentang

PEDOMAN PPI di
Fasyankes
 PERANAN STRATEGIS PROGRAM PENCEGAHAN DAN
PENGENDALIAN INFEKSI DALAM PPRA
 Antibiotic stewardship programs (ASP) have been shown to
o Improve patient outcomes,
o Reduce antimicrobial agent-related adverse events,
o Decrease antimicrobial resistance (AMR).

 However, prevention is better than cure and it is important

that all clinicians depend on evidence-based IPC
interventions to reduce demand for antimicrobial agents by
preventing healthcare associated infections from occurring in the
first place, and making every effort to prevent transmission when
they occur.
PENINGKATAN PROGRAM PENCEGAHAN DAN PENGENDALIAN INFEKSI
TERKAIT PROGRAM RESISTENSI ANTIMKIROBA

 The issues surrounding the prevention and control of

infections are intrinsically linked with the issues associated with
the use of antimicrobial agents and the proliferation and spread
of AMR.

 The vital work of infection prevention and control (IPC)

programs and ASPs cannot be performed independently and
requires interdependent and coordinated action across
multiple and overlapping disciplines and clinical settings.

PPI DAN PPRA SALING BERKETERGANTUNGAN DAN KOORDINASI

RESEPKAN ANTIBIOTIK SAAT DIPERLUKAN

 Antibiotics can be life-saving when treating

bacterial infections but are often used
inappropriately, specifically when
unnecessary or when administered for
excessive durations or without consideration of
pharmacokinetic principles.

 Antibiotics should be used after a treatable

infection has been recognized or when
there is a high degree of suspicion for
infection.
RESEPKAN ANTIBIOTIK DENGAN DOSIS
ADEKWAT

 Initial antimicrobial therapy in patients with surgical infections is typically empirical in nature because
especially critically ill patients need immediate treatment, and microbiological data (culture and
susceptibility results) usually requires ≥24 h for the identification of pathogens and antibiotic
susceptibility patterns.
 Empirical antimicrobial therapy should be based on local epidemiology, individual patient risk factors
for difficult to treat pathogens, clinical severity of infection, and infection source.
 Knowledge of local rates of resistance should be an essential component of the clinical decision-
making process when deciding on which antimicrobial regimen to use for empiric treatment of infection.
Every clinician starting empiric therapy should know the local epidemiology.
 Surveillance initiatives are important, both in a local and in a global context.
RESEPKAN ANTIBIOTIK DENGAN DOSIS
ADEKWAT

 Generally, the most important factors in predicting the presence of resistant pathogens in surgical
infections is acquisition in a healthcare setting (particularly if the patient becomes infected in the ICU
or has been hospitalized for more than 1 week), corticosteroid use, organ transplantation, baseline
pulmonary or hepatic disease, and previous antibiotic therapy.
 Previous antibiotic therapy is one of the most important risk factors for resistant pathogens.
 Inappropriate therapy in critically ill patients may have a strong negative impact on outcome.
 An ineffective or inadequate antimicrobial regimen is one of the variables more strongly associated
with unfavorable outcomes in critically ill patients.
 Broad empiric antimicrobial therapy should be started as soon as possible in patients with organ
dysfunction (sepsis) and septic shock.
 RESEPKAN ANTIBIOTIK DENGAN DOSIS
ADEKWAT

 Finally, selection of empirical therapy should take into account the infection source because
etiological distribution varies according to the source site.
 The antibiotic dosing regimen should be established depending on host factors and properties
of antimicrobial agents.
 Antibiotic pharmacodynamics integrates the complex relationship between organism
susceptibility and patient pharmacokinetics.
 Pharmacokinetics describes the fundamental processes of absorption, distribution, metabolism,
and elimination and the resulting concentration-versus-time profile of an agent administered in
vivo.
 The achievement of appropriate target site concentrations of antibiotics is essential to
eradicate the relevant pathogen. Suboptimal target site concentrations may have important
clinical implications, and may explain therapeutic failures, in particular, for bacteria for which in
vitro MICs are high.
 SESUAIKAN ANTIBIOTIK SAAT HASIL
BIAKAN TERSEDIA

 The patient should be reassessed when the results of microbiological testing are available.

 The results of microbiological testing may have great importance for the choice of therapeutic
strategy of every patient, in particular in the adaptation of targeted antimicrobial treatment.

 They provide an opportunity to expand antimicrobial regimen if the initial choice was too
narrow but also allow de-escalation of antimicrobial therapy if the empirical regimen was too
broad.

 Antibiotic de-escalation has been associated with lower mortality rates in ICU patients and
is now considered a key practice for antimicrobial stewardship purposes
 GUNAKAN ANTIBIOTIK DENGAN MASA
PENGGUNAAN TERPENDEK BERBASIS BUKTI

o Duration of therapy should be shortened as much as possible unless there are special
circumstances that require prolonging antimicrobial therapy such as immunosuppression, or
ongoing infections.
o Oral antimicrobials, can substitute IV agents as soon as the patient is tolerating an oral diet so as
to minimize the adverse effects which are associated with intravenous access devices.
o Where possible, conversion to oral antimicrobial agents having high oral bioavailability (e.g.
fluoroquinolones) should be considered.
o Patients who have signs of sepsis beyond 5 to 7 days of treatment warrant aggressive diagnostic
investigation to determine if an ongoing uncontrolled source of infection or antimicrobial
treatment failure is present.
o In the management of critically ill patients with sepsis and septic shock clinical signs and
symptoms as well as inflammatory response markers such as procalcitonin, although debatable,
may assist in guiding antibiotic treatment.
 EDUKASI STAF

 Education is fundamental to every ASP. A range of factors such as diagnostic uncertainty, fear
of clinical failure, time pressure or organisational contexts can complicate prescribing decisions.
 However, due to cognitive dissonance (recognising that an action is necessary but not
implementing it), changing prescribing behaviour is extremely challenging.
 Efforts to improve educational programs are thus required and this should preferably be
complemented by active interventions such as prospective audits and feedback to clinicians to
stimulate further change.
 It is also crucial to incorporate fundamental ASP and IPC principles in under and post graduate
training at medical faculties to equip young doctors and other healthcare professionals with
the required confidence, skills and expertise in the field of antibiotic management.
 LAKSANAKAN SURVEILANS PGA
DAN HAI SERTA PEMANTAUAN
KONSUMSI ANTIBIOITK

 Monitoring of antibiotic consumption should be implemented and feedback provided to all

ASP team members regularly along with AMR or healthcare-associated infections (HAIs)
surveillance data and outcome measures.

 HAI is a patient safety and quality of healthcare issue which contributes to poor patient
outcomes and additional costs to the health care system.

 Surveillance to determine the incidence of HAI is an important part of the strategy to

minimise the occurrence of these infections.
 DUKUNG PENDEKATAN INTERDISIPLIN

 Promotion of ASPs across clinical practice is crucial to their success to ensure standardization of antibiotic
use within an institution. We propose that the best means of improving antimicrobial stewardship should
involve collaboration among various specialties within a healthcare institution including prescribing
physicians. Successful ASPs should focus on collaboration between all healthcare professionals to shared
knowledge and widespread diffusion of practice. Involvement of prescribing physicians in ASPs may rise
their awareness on antimicrobial resistance.
 It is essential for an ASP to have at least one member who is an infectious diseases specialist.
 Pharmacists with advanced training or longstanding clinical experience in infectious diseases are also key
actors for the design and implementation of the stewardship program interventions.
 In any healthcare setting, a significant amount of energy should be spent on infection prevention and
control. Infection control specialists and hospital epidemiologists should be always included in the
ASPs to coordinate efforts on monitoring and preventing healthcare-associated infections.
 DUKUNG PENDEKATAN INTERDISIPLIN

 Microbiologists/Clinical Pathologists should actively guide the proper use of tests and the flow of laboratory
results. Being involved in providing surveillance data on antimicrobial resistance, they should provide periodic
reports on antimicrobial resistance data allowing the multidisciplinary team to determine the ongoing burden
of antimicrobial resistance in the hospital. Moreover, timely and accurate reporting of microbiology
susceptibility test results allows selection of more appropriate targeted therapy, and may help reduce broad-
spectrum antimicrobial use.
 Surgeons with adequate knowledge in surgical infections and surgical anatomy when involved in ASPs may
audit antibiotic prescriptions, provide feedback to the prescribers and integrate best practices of antimicrobial
use among surgeons, and act as champions among colleagues implementing change within their own sphere of
influence. Infections are the main factors contributing to mortality in intensive care units (ICU).
 Intensivists have a critical role in treating multidrug resistant organisms in ICUs in critically ill patients. They
have a crucial role in prescribing antimicrobial agents for the most challenging patients and are at the forefront
of a successful ASP.
 DUKUNG PENDEKATAN INTERDISIPLIN

 Emergency departments (EDs) represent a particularly important setting for addressing inappropriate
antimicrobial prescribing practices, given the frequent use of antibiotics in this setting that sits at the
interface of the community and the hospital. Therefore, also ED practitioners should be involved in the
ASPs. Without adequate support from hospital administration, the ASP will be inadequate or inconsistent
since the programs do not generate revenue.
 Engagement of hospital administration has been confirmed as a key factor for both developing and
sustaining an ASP.
 Finally, an essential participant in antimicrobial stewardship who has been often unrecognized and
underutilized is the “staff nurse.” Although the role of staff nurses has not formally been recognized in
guidelines for implementing and operating ASPs they perform numerous functions that are integral to
successful antimicrobial stewardship. Nurses are antibiotic first responders, central communicators, as
well as 24-hour monitors of patient status.
KESIMPULAN

 Resistensi antimikroba masih merupakan masalah

kunci dalam kesehatan.
 Ada lima tujuan strategis rencana aksi PGA
 PGA merupakan salah satu dari tiang pendekatan
terpadu untuk memperkuat sistim Kesehatan,
pilar lainnya adalah PPI dan keselamatan pasien
dan pengobatan
 Pendekatan harus dilakukan secara interdisiplin
o PPI dan PPRA merupakan dua sisi dari mata
uang yang tidak mungkin dipisahkan
TERIMA KASIH