Professional Documents
Culture Documents
Antibiotics
Prudential Use of Antibiotic in Adult
dr. Rizky
Perdana,SpPD,KPTI,FINASIM
Facta di Klinik
Antibiotic Resistance
A worldwide problem1
Associated with
increased morbidity,
mortality, and
hospital costs1
Occurs in both
hospitals and the
community2
1: R. A. Kulkarni et al. Indian J Surg. 2005: Volume 67(6): 308-315.
2 Ben-David D, Rubenstein E. Curr Opin Infect Dis 2002;15:151-156.
Current Problems of
Bacterial Resistance
Policy & Advocacy of IDSA; July 2004
B AD B UGS , N O D RUGS
As Antibiotic Discovery Stagnates A Public Health Crisis
Brews
Native
Organisms
Perl TM. Gram Negative Bacterial Resistance in Healthcare: The Brave New World Healthcare
Antimicrobial Resistance:
Prevent
Transmission
Infection
Antimicrobial
Resistance
Effective
Diagnosis
& Treatment
Optimize &
Rational
Use
Antimicrobial Use
Microbiology
Antibacterial spectrum
Drug
PK
Absorption
Distribution
Metabolism
Excretion
Optimal dosing
regimen
(Scaglione,
2002)
Clinical efficacy
Bacterial eradication
Compliance with
dosing regimen
Tolerability
Rate of resolution
Prevention of resistance
Mechanism of action
Concentration
at infection site
Pathogen MIC
PD
Rational Antimicrobial
Therapy
Clinician
Drug
Patient
Microorganism
Microbiologist
Kidney:
Effect on passive
readsorbtion &
active secretion
Bowel:
Other drug or food
modifies absorbtion
Drug interaction
Plasma:
Competitition for
protein binding
sites
Liver:
Receptor sites:
Induction of liver enzymes -Drugs may compete
modified excretion
at binding site
Examples of
Antibiotics-Drugs Interactions
Site
IV fluids
Many
GI tract
Tetracyclines
Quinolones
Absorbtion by food
Absorbtion reduced by iron
Aminoglycosides
Antibiotic Usage in
Clinical Practice
Microbiological result
Factors Involved in
Optimal Initial Antibiotic
Therapy
Increased
Antimicrobial Combination:
When we need?
Unknown focus of infection
Polymicrobial infection, eg: abscess caused
by multiple aerob and anaerob organisms
Decrease resistance rate, eg: Tb treatment
Decrease dose related toxicity
Increase antimicrobial potency
Outpatie
nt
Stable
condition
Escalatio
n
Severe/ high
risk
Deescalation
Antibiotic monotherapy or
combination
Ventilator-associated pneumonia
Nosocomial pneumonia
Blood stream infection
Severe community-acquired pneumonia
Meningitis
Sepsis
ICU patient
De-escalation Approach to
Antimicrobial Utilization
Obtain appropriate microbial sample
for culture and special stain
Search for
superinfection,
abscess
formation,
non-infectious
caused of
fever
No
Yes
Antibiotics in De-escalation:
Combining Rapid and Appropriate
Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Crit Care Med 2008; 36(1): 296-327
P<0.001
P<0.001
P<0.001
De-escalation Approach to
Antimicrobial Utilization
Obtain appropriate microbial sample
for culture and special stain
Search for
superinfection,
abscess
formation,
non-infectious
caused of
fever
No
Yes
Colonization
No treat
Optimized
Pathogen
Sensitive
Resistant
Treat with
Antibiotics
Recommended
Antibiotics
Combination
PKPD
Antibiotic Policy
Classification of antibiotics
Class A : Not restricted
Class B : Not restricted, under
supervision
Class C : Restricted
Implementation
Evaluation and surveillance
Auditing
Classification of Antibiotics
Class A
Aminoglicoside
Penicillin
Cephalosporin
gen.I,II
Chloramphenicol
Fucidic acid
Lincosamide
Macrolide
Nitroimidazol
Fluoroquinolone
gen.I,II
Tetracyline
TMP-SMX
Fosfomicin
Polypeptide
Class B
Cephalosporin
e
gen III
Fluoroquinolo
ne
gen III-IV
Ertapenem
Vancomycin
Class C
Teicoplanin
Linezolide
Cefepime
Cefpirome
Ceftazidime
Pip-Tazo
Carbapenem
Tygecicline
Implementation of
Antimicrobial Policy in Hospital
Outpatient
Community
Hospital
Class A
Class A
Class B
Class C
Class B/C
Class C
Inpatient
WAR
D
ICU
Mild
Moderat
e Severe
Evaluation category of
Antibiotics Usage by Gyssens
I.
II.
Correct Usage
Incorrect due to:
a) Incorrect dose b) Incorrect interval c) Incorrect route
III.
IV.
V.
VI.
No Indication
Medical record is insufficient to be
evaluated
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
Conclusions
Types of antibiotic usage: empirical,
definite, prophylaxis, pre-emptive
Rational antibiotic therapy: rapid,
appropriate, cost effective
The implementation of antibiotic policy to
promote:
rational use of antibiotics,
cost-effective therapy,
prevent collateral damage