Prof.DR.Kuntaman,dr.

,MS,SpMK(K)

• Advisor KPRA KEMENKES R.I

• Advisor KPRA RSUD Dr.Soetomo
• Ka.Prodi Magister/S2 Ilmu Kedokteran
Dasar FK UNAIR
• Ketua Dewan Etik FK UNAIR
• Ketua PAMKI Pusat
Surveilans of AMR (MDRO) in
Indonesia

Kuntaman
FK Universitas Airlangga/RSU Dr. Soetomo Surabaya
Komite Pengendalian Resistensi Antimikroba
Kementerian Kesehatan Republik Indonesia
kuntaman@fk.unair.ac.id, 08113410352

Pelatihan PPRA & SNARS, Surabaya, Jan,19-21, 2018

 Problem Statement
• Surveillance: is the monitoring of the
behavior, activities, or other changing
information, usually of people for the purpose
of influencing, managing, directing, or
protecting them (Health Services)
• Focus AMR &/or AMU
• Indicator: ?? (should be determined): National
– Evidence based
– Sensitive to be monitored
– Higher impact in clinical setting  Inf Dis
The Surveillance Steps
• Commitment
• Situation analysis
• Governance
• Mapping
• stakeholder involvement
•  for developing/strengthening
the existing system (in every
ward/center)

IDSA Guidelines. Clin. Inf. Diseases Advance Access published July 10, 2013
The Surveillance Steps
• Funding and Priority
• Approach: Bottom-up & Top-down
• Effectivity and Efficiency
• Networking: Local, Regional, Global
• Minimal requirements of
participants/centers: Assessment
Global Antimicrobial
Resistance Surveillance
System
 GLASS-2014

Bacterial Indicator AB
1. E coli SXT, QNs, C3rd,Carb,Col,AMX
2. K pneumoniae SXT, CIP, C3rd,Carb,Col,AMX
3. Acin baumannii AN, TGC, Carb, Col
4. Sta aureus FOX, MRSA?
5. Strep pneumo OXA, Pen, SXT, CRO/CTX
6. Salmonella spp QNs, C3rd, Carb
7. Shigella spp QNs,C3rd,Azithro
8. N gonorrhoeae FIX, CRO, Azithro
 GLASS-2014

Specimen Bacteria
1. Blood E. coli; K. pneumoniae; A. Baumannii;
S. aureus
S. pneumoniae; Salmonella spp.
2. Urine E coli, K. pneu
3. Faeces Salm, Shigella
4. Urethra, Cx N go
Metric Measurement

Specimen Measurement = Indicator

1. Urine Num: Pathogen/s identified vs AST
Deno: Total Urine sample
Num: E coli & ESBL+
Deno: Total E coli
Num: E coli & Cip-Res
Deno: Total E coli
2. Blood Num: E coli in Spesis Pts
Deno: Total Population (per 100.000 Pop)
 Indonesia Surveillance
on AMR/MDRO &/or AMU
(Antimicrobial Use)
MDRO: sangat banyak
• Surveillance:
–Semua: ??
–Indikator spesifik: ??  Apa: ??
–Murah & Manfaat ++
MDRO: Multiple Drug Resistant Organisms

• Resistance against minimally 3

Classes of Antibiotics
• Ex:
–Ceph, FQ, Amino
–FQ, TGC, MEM
–ERY, DA, TET
–SXT, ERY, GEN
ESBL: Extended Spectrum Beta Lactamase

• Mostly Gram neg Bacteria

• Resistance against:
– Ceph-3rd
– Aztreonam
– Cross: FQ
– Others: ??
• Data Indonesia: Sensitive: AK, FOS,
MEM, TGC, PTZ/SCF
 Plan
• Active Surveillance:
– Active, targeted surveillance
– High cost
• Passive Surveillance:
– Low Cost Surveillance
– Based on Routine data on Health
Care Services
– Centers: Hospitals
 Passive surveillance
WHAT:
- The routine Lab Examination, paid by
system (Insurance)
- Centers: Hospital-2, 3 & Facilities: ?
- Many centers, representative of Regional,
National (Indonesia)
- Beneficial for Health Services & National
Policy  Handling of Inf Dis
Target Selection:
• Ward: Surgical vs Medical
• Disease & Specimen:
– Pneumonia  Sputum
– UTI  Urine
– SSI  Pus
• Hospital:
• Time: 2018
• Pathogens: Rank
 Target Resistant Bacterial :
• All bacterial pathogens
• Specific bacterial Resistance:
– ESBL Producing bacteria
– MRSA
– Carbapenem Resistant Pseudo
aeruginosa
• Now in Indonesia:
– ESBL: range about 45-82%
– MRSA: range about 30-50%
An Example
1. The Prevalence & Susceptibility pattern of ESBL
Producing bacteria in Dr. Haz Hospital Malang
2017
2. The pattern of bacterial agents and its
susceptibility among sputum isolates in Dr Hiz
Hospital Mojokerto 2017
3. The prevalence and susceptibility pattern of MRSA
and MSSA in Huv Hospital Magetan 2017
4. The ESBL producing bacterial agent from Sputum
and Urinary specimen in Han Hospital Solo 2017
 An Example
1. The Prevalence & Susceptibility pattern of
ESBL Producing E coli and Kl pneumoniae in
Dr. Haz Hospital Malang 2017
 Why E coli & K pneumo:  80-90% ESBL
 Prevalence in: (E coli or K pneu or both)
• Sputum
• Urine
• Blood
• Pus
 Susceptibility ESBL-E coli or K pneumo or
Both against: CTX, CRO, FEP, AMC, AK,
PTZ, SCF, MEM,
 ESBL Multicentre Study Jan-June 2010
Surabaya, Semarang, Malang
Producing microbes Total %
Citrobacter freundi 1 0.5
Citrobacter koseri 1 0.5
Citro werkmanii 1 0.5
Ent aerogenes 1 0.5
Entero cloacae 12 6
E coli 91 44
Kleb oxytoca 2 1
Kleb pneumo 93 45
Proteus mir 1 0.5
Seratia fonficola 1 0.5
Seratia marcescens 1 0.5
Total 205 100 20
 All Isolates Jan 2010 until June 2010
ESBL Producers Surabaya, Semarang, Malang

E coli (n=91) Kleb pne (n=93)

Antibiotic Res (%) Res (%)
Cefotaxim 89 97,8 87 93,55
Meropenem 0 0 3 3,23
Fosfomycin 4 4,4 3 3,23
Cefo-Sulb 3 3,3 4 4,30
Amikacin 7 7,7 8 8,60
Ciprofloxacin 68 74,7 43 46,24 21
 Isolates Jan 2010 until June 2010
Specimens: ESBL Producers SBY, MLG
E coli (%) Kleb pne (%)
Sby Malang Sby Malang
Specimen (n=46) (n=18) (n=44) (n=26)
Urine 46 39 22 19
Blood 8 11 13 8
Pus 13 33 29 35
Sputum 11 11 31 31
Faeces 20 6 0 4
Others 2 0 5 4
22
 Summary
• Surveillance targeting on: AMR & MDRO
• Plan: Active vs Passive
• Passive Surveillance  Low Cost: Cost paid by
Health Care System
• Specify:
– Selected ward or whole hospital wards
– Specified specimen: Blood, Sputum, Pus ??
– Specified Time: Jan-July 2018
– Specify: Targeted Bacteria: ESBL, MRSA,
Acinetobacter baumanii ??