Rational Antibiotic

Usage
and Antibiotic Policy
Indonesian Society of Infection Control / INASIC
Perhimpunan Pengendalian Infeksi Indonesia /
PERDALIN

Antibiotics
Antibiotic class.
Mechanism of action.
Pharmacology
Pharmacokinetics
Pharmacodynamics

Classification of
Antimicrobial Drugs
Bactericidal

Beta-lactam
Penicillin
Cephalosporins
Carbapenems
Monobactam
Glycopeptides
Oxazolidinones
Aminoglycosides
Fluoroquinolones

Bacteriostati
c

Tetracycline
Macrolides
Lincosamides
Chloramphenicol
Nitrofurantoin

Sulfamethoxazole
Trimethoprim

Mechanism of antibiotics
kill or inhibit
microorganism

Inhibition or disruption of cell wall growth.

Inhibition of protein synthesis.

Interference with DNA or RNA synthesis.

Inhibition of membran function.

AM Classification & Mode of

Action
Inhibition of cell
wall synthesis
Penicilin,
Cephalosporin,
Monobactam,
Carbapenem,
Glucopeptide,
Fosfomysin,
Oxasolidine

Inhibition of protein
biosynthesis
Aminoglycoside,
Lincosamide,
Macrolide,
Tetracycline/Tygecyclin
Chloramphenikol,
Fusidic acid

Folic acid
antagonists
Sulfa-Trimethoprim,
Cotrimoxazole

Damaging of cytoplasmic
membrane
Aminoglycoside, Polymixin B,
Colistin, Amphotericin B

Inhibition of
nucleic acid
synthesis
Rifampicin,
Fusidic acid,
Quinolone.

b-lactamase
inhibition
Clavulanic acid,
Sulbactam,
Tazobactam

Protein
synthesis
inhibition
Macrolides
erythromyci
n
midecamyci
n, etc.
Chlorampheni
col

Aminoglycosid
es kanamycin
dibekacin
amikacin
streptomycin
Tetracycline
s
Cytoplasm
ic
membrane
inhibition
Polypeptides
polymixin B,
etc.

Cell wall
synthesis
inhibition
FOM
(Fosfomycin)

Penicillins
penicilin-G
ampicillin
cloxacillin,
etc.

Cephems
cephalosporin
s
cephamycins
Inhibition of
nucleic acid
synthesis
DNA synthesis
inhibition Quinolones

RNA synthesis
inhibition rifampicin

CLASSIFICATION OF CHEMOTHERAPEUTIC
AGENTS BY MECHANISM OF ACTION

Spectrum of antimicrobial
Range of microorganism an antibiotics
is usually effective against.
Base on local susceptibility data
Basis of empirical antimicrobial
therapy

Principles of Antimicrobial
Therapy
Selective toxicity is the ability to kill
or inhibit the growth of
microorganism without harming the
cells of the host.
Reach the site of infection at
inhibitory concentrations.
Penetrate and bind to target.

Factors that influence the

tissue penetration of
antimicrobial

Antibiotics properties
lipid solubility, molecular size.
Tissue
adequacy of blood supply
presence of inflammation
(acute/chronic).
Intracellular infection, abscess,
implanted
prosthetic material.

Antimicrobial
Combination

To extent the spectum of cover empirical

therapy of suspected mixed infection
(febrile neutropenia, intraabdominal
infection)
To achieve bactericidal effect (synergy)
(Enterococcal infection)
To prevent emergence of resistant
microorganism
(Treatment of tuberculosis)

Antimicrobial resistance

Natural or acquired
Relative or absolute
Community or hospital
Antibiotic characteristic to resistance
- agent specific
- related to volume or duration of used
- low or high potential of resistance

Antimicrobial Resistance
Community Infections :
Pneumonia
Dysentery
Typhoid
Gonorrhoea
Tuberculosis

Strep. pneumoniae
Shigella dysenteriae
Salmonella typhi
Neisseria gonorrhoeae
Mycobacterium tuberculosis

Penicillin resistant.
multiresistant.
multiresistant.
Pen & Tetra resist.
MDR-TB.

Nosocomial infections :
Staph. aureus
Enterococcus spp.
Klebsiella; Pseudomonas

Meth (& vanc) resist.

Vancomycin resistant.
multiresistant.

Factors that influence of

antimicrobial cost

Early switch from iv to oral

Use antibiotics with long half life
Choosing monotherapy or combination
Antibiotics side effects
Antibiotics failure due to resistant
microorganism

Pharmacokinetic / Pharmacodynamic
Relationships : Surrogate Markers

Concentration (mg/L)

Cmax = Peak serum concentration

AUC = Area under the concentration vs.

time curve

T> MIC

MIC = Minimal inhibitory

concentration

Time (h)

Cmin = Trough
Jones, 2003

Time dependent and

concentration dependent
antibiotics
A.

Concentration dependent
Increased bactericidal effect correlates
with increased drug concentration.
e.g. Aminoglycosides, quinolones

B.

Time dependent
Bacterial killing has little relationship to
concentration, as long as the antibiotic
level at the site of infection above MIC.
e.g. beta-lactam, vancomycin

A. CONCENTRATION DEPENDENT
KILLING ANTIBIOTICS
Aminoglycosides,
Fluoroquinolones,
Metronidazole, Amphoterin B
Cmax / MIC (10 12)
optimal bacterial activity prevent
bacterial growth 24 hours.

B. TIME DEPENDENT KILLING

ANTIBIOTICS
Beta-Lactams, Glycopeptides,
Macrolides, Clindamycin,
Oxazolidinediones.
Rate & extent of killing constantly, if
concentration MIC.
Duration of drug concentration MIC for pathogen
at site of infection, as long as possible during dosing
interval.

Major route of antibiotics

elimination
Hepatobilliary
Chloramphenicol
Cefoperazone
Doxycicline
Macrolide
Clincamycin
Metronidazole
Moxifloxacin
Rifampicin
INH/Pirazinamide
Nafcillin
Itraconazole
Ketokonazole
Voriconazole

Renal
Most beta-lactam
Tetracyclin
Aminoglycoside
Flucytocin
TMP-SMX
Acyclovir
Monobactam
Valacyclovir
Carbapenam
Polimyxin
Ciprofloxaxin
Ofloxacin
Levofloxacin
Gatifloxacin
Vancomycin
Fluconazole

Dosing Strategy in
Hepatic/Renal insufficiency

Hepatic Insufficiency
Decrease total daily dose of hepatically eliminated
antibiotic by 50% in presence of clinically severe liver
diseases. Or use antibiotics by renal route in usual dose .

Renal Insufficiency
If Creatinine clearence 40-60 ml/min, decrease dose of
renal eliminated antibiotics by 50%
If Creatinin clearence 10-40 ml/min, decrease dose of
renal eliminated antibiotics by 50% and double the
dosing intervals
Alternative : use antibiotic inactivated by hepatic route

Introduction of New Classes of

Antibiotics
1940

1960

1980

2000

Sulfonamides 1936
-lactams 1940
Cephalosporins 1945
Chloramphenicol 1949
Tetracyclines
Aminoglycosides 1950

Oxazolidinones 2000
Lipopeptides 2003
Ketolides 2004

Macrolides 1952
Glycopeptides 1958
Quinolones
Streprogramins 1962
Trimethoprim 1968
Wenzel RP. NEJM. 2004;351:523
526.

Antibiotic Resistance

A worldwide problem1

Associated with increased

morbidity, mortality, and
hospital costs1

Occurs in both hospitals

and
the community2

Results from factors such

as antibiotic misuse1

Source:
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

Increasing Antimicrobial Resistance

Among Pathogens Causing HospitalOnset Infections3
Third-generation cephalosporinresistant Klebsiella pneumoniae

Fluoroquinolone-resistant
Pseudomonas aeruginosa
30

Resistance (%)

12
10
8
6
4

25
20
15
10
5

0
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00

19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00

Resistance (%)

14

Nonintensive care unit patients

Intensive care unit patients
Source: US National Nosocomial Infections Surveillance System (NNIS)
Ref 3: Adapted from Centers for Disease Control and Prevention (CDC). Available at
http://www.cdc.gov/drugresistance/healthcare/ha/HASlideSet.ppm. Accessed August 2005.

Changing trend of nosocomial res

1998-2002 NNIS

VRE

2003 NNIS

% increase
12 %

28.5 %

MRSA

11 %

59.5 %

3rd-R E.coli

0%

5.8 %

3rd-R Kleb.

47 %

20.6 %

3rd-R Enterobac.

-6 %

31.1 %

3rd-R Pseudo.

20 %

31.9 %

IMP-R Pseudo.

15 %

21.1 %

FQ-R Pseudo.

9%

29.5
%

10

20

30

40

50

60

70

80

90

(% resistance)
NNIS. Am J Infect Control. 2004;32:470.

Emerging Resistant Pathogens

Causing Hospital-Acquired
Intensive Care Unit
Gram positive pathogen

Methicillin-R Staphylococcus aureus

Vancomycin-R enterococci

Gram negative pathogen

Imipenem-R Pseudomonas spp.

Fluoroquinolone-R Pseudomonas spp.
3rd generation cephalosporin-R E. coli
Extended spectrum betalactamase

* Percent increase in proportion of pathogens resistant to indicated antimicrobial

Susceptibility Pattern of Some Pathogens in

Dr. Cipto Mangunkusumo Hospital JanuaryMay 2007

Microbiological Laboratory Dept of Clinical

Pathology Dr. Cipto Mangunkusumo
Hospital

Microbiological Pattern of Diabetic

foot infections in
Dr. Cipto Mangunkusumo Hospital
2004

Monomicrobial 40%
Polymicrobial 60%
Aerob gram positive 35 isolates
Aerob gram negative 56 isolates
Anaerob 6 isolates

Microbiological Pattern of Diabetic foot

infections in
Dr. Cipto Mangunkusumo Hospital 2004
(n=96 isolates)

E coli 17.7%
S aureus 15.6%
S beta-hemolytic 13.5%
P mirabilis 11.5%
E aerogenes 8.3%
P aeruginosa 5.2%
K pneumonia 5.2%
Strep anhemolytic 4.2
Bacteroides sp 4.2%
Acinetobacter 2.1%
K ozeanae 2.1%

Microbiological Pattern of Diabetic foot

infections in
Dr. Cipto Mangunkusumo
Hospital 2004
(n=96 isolates)

Staf aureus n=17 - MRSA 24%

E coli n=21 3rd gen res E coli 24%
K pneumonia 3rd gen res K pneu
40%
3rd gen resistance pseudomonas 13%
FQ resistance pseudomonas 37%
Carbapenem resistance
pseudomonas 0%

Interaction in Antibiotic
Usage
HOST
HOST

PHARMAC
O
KINETICS

DEFENCE

PATHOGE
N

PHARMAC
O
DYNAMIC
S

ANTIBIOTIC
S

Consideration in Antimicrobial
Usage
Is antimicrobial needed ?
How to choose antimicrobial agent ?
Indication of antimicrobial ?
Prophylactic, empirical treatment
definite/directed treatment
Oral or parenteral therapy?

General Principle in Antimicrobial

Usage

Microbiology guide
Indication evidence based
Narrowest spectrum
Appropriate dosage
Minimized duration
Ensure monotherapy
except in special
condition

Conclusion:
How To Choose Antibiotic(s)?
PATIENT
age
immunity
previous ATB

PK/PD

Epidemiology

Infection
Type
MICROORGANISM

Local Resistance

Consideration When Choosing an

Antibacterial Agent
Outcome

Microbiology
Mechanism of action
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
Cost effectiveness

Concentration
at infection site

Pathogen MIC
PD

Time vs. concentration

dependent killing
Bactericidal vs. bacteriostatic activity
Tissue penetration
Persistence of antibacterial effect

FAILURE of ANTIMICROBIAL
TREATMENT
FALSE FAILURES
Erroneous initial diagnosis
Underlying disease uninfluenced by the antibiotic
Unjustified impatience
Inactivation of the antibiotic before or during its
administration
FAILURES LINKED TO THE PATIENT
Lack of proper compliance

Insufficient
antibiotic
bioavailability
(oral
administration:
Vomiting, diarrhea; parenteral administration: lack of
correct
perfusion, etc)
Immunosuppressed host

FAILURE of ANTIMICROBIAL
TREATMENT
PHARMACOLOGIC FAILURE
Insufficient amount of drug
Insufficient drug penetration at the site of infection
Lack of proper consideration of the pharmacodynamic
parameter in
setting the administration schedules and conditions
Lack of insufficient bactericidal effect
Antagonism between antibiotics used
Lack of in situ activity because of the local conditions
Absence of proper drainage

FAILURES RELATED TO THE INFECTING PATHOGEN

Error of pathogen identification
Acquisition of resistance during treatment
Inoculum effect
Bacterial persistence
Tulkens, P. M. ; OCS on Resistance and the Use and Misuse af
Therapy ; June 2000

Antimicrobial

Common error in
Antimicrobial prescribing

Treatment of colonization
Suboptimal empiric treatment
Inappropriate combination therapy
Dosing and duration error
Mismanagement of apparent
antibiotics failure

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Antimicrobial Resistance:

Key Prevention Strategies

Antimicrobial-Resistant
Pathogen
Susceptible
Pathogen
Pathogen

Prevent
Transmission

Antimicrobial
Resistance

Prevent
Infection

Infection
Effective
Diagnosis
and Treatment

Optimize
Use

Antimicrobial
Use

Practical Guide of antibiotic

selection
Indications

Prophylaxis
Empirical treatment
Definite treatment

Antimicrobial
prophylaxis

Effective chemoprophylaxis
Post exposure prophylaxis
(meningitis, viral influenzae, Gonococcal
infection,
syphilis, shigellosis, tuberculosis, malaria)
Surgical prophylaxis
Immunocompromised
Inconclusive chemoprophylaxis
Post streptococcal glomerulonephritis
Clostridial infection
Infective endocarditis
Chronic obstructive pulmonary diseases
Cystic fibrosis
Post splenectomy
Ineffective chemoprophylaxis

Strategy for empirical treatment

Patient
Outpatient

Hospitalized
Stable condition
Escalation

dysfunction

Deescalation

Antibiotic selection based on

Susceptibility and resistance pattern
Immunity status, co morbidity and organ

Antibiotic monotherapy or combination

Pohan HT, 2005

Severe or high risk

De-escalation approach to antimicrobial

utilization
Serious hospital acquired infection suspected
Obtain appropriate microbial

sample for culture and special stain

Begin empirical antibacterial treatment with

a combination agents targeting the most common
pathogen based on local data
Follow clinical parameter : Temp, WBC, CXR
PaO2/FiO2, haemodynamic, organ
function
De-escalating antibacterial based on results of
clinical microbiology data
Search for superinfection
Abscess formation
Non infectious caused
of fever

Significant clinical improvement

after 48-96 hours
Y
Discontinue antibacterial after 7-14 days course based
on site of infection and clinical response
Kollef, Drugs 2003;63 (20): 2157

Definite treatment

Based on microbiological result

Microbiological examination
Sample collection
Sample transportation
Laboratory analysis
Interpretation
Evaluation of empirical antibiotic
used

Antimicrobial Treatment based on

Microbiological Culture Results
Microbiological culture
results
Colonizatio
n

MDR

Pathogen
Sensitive

Resistant

No Treat
Treat with
Antibiotics
Recommende
Combination
d Antibiotics

Optimized
PK/PD

Interaction in Antibiotic
Usage
HOST

PATHOGE
N

ANTIBIOTIC
S

Microbiology
Microbial caused.
Susceptibility pattern.
Resistance pathogen.
Antimicrobial spectrum.

Microbiology of Peritonitis
Primary
(Monomicrobial)

Secondary
(Polymicrobial)

Tertiary
(Polymicrobial)

E. coli
Klebsiella spp.
Streptococcus spp.
Enterococcus spp.
Other gram-negative
bacilli

B. fragilis group
E. coli
Clostridium spp.
Klebsiella spp.
Streptococcus spp.
Enterococcus spp.
Pseudomonas
spp.

Enterococci
Pseudomonas
S. epidermidis
Candida

Laroche M, et al. Eur J Clin Microbiol Infect Dis. 1998;17:542-550.

Barie PS. J Chemother. 1999;11:464-477.

DIABETIC FOOT INFECTIONS :

MICROBIOLOGY

Predominant pathogens
Aerobic gram-positive cocci Staph. aureus
and
hemolytic strep (esp GBS)

Chronic wounds
Complex flora: Enterobacteriaceae,
enterococci, obligate anaerobes,
Pseudomonas aeruginosa

Resistant pathogens: MRSA, VRE

Lipsky BA, et al. Clin Infect Dis. 2004;39:885-910.

Interaction in Antibiotic
Usage
HOST

PATHOGE
N

ANTIBIOTIC
S

Host

Susceptible
(elderly, pregnancy)
Immunocompromised
(cancer chemotherapy,
immunosuppressive, organ transplant,
HIV)
Comorbid
(diabetes mellitus, chronic kidney
diseases/dialysis, congestive heart
failure, cerebrovascular diseases)
Organ dysfunction
(renal/liver dysfunction)

Principles of
Antibiotic Policies
International Federation of Infection Control
Basic Concepts of Infection Control
Editors : Friedman and Newson
N Ireland, UK 2007

KEY POINTS

Resistant bacterial strains are selected in hospitals

due to huge usage of antibiotics
To preserve the susceptibility of microorganism, and
postpone the development of resistance, antibiotics
should be used rationally
If resistant bacteria develop in an environment
where the specific antibiotic used, they will become
prevalent in that environment
Good antibiotic prescribing practices should be
encouraged within hospitals
The microbiology laboratory service can asisst
clinicians to use targeted antibiotic treatment for
patients

ANTIBIOTIC STEWARDSHIP

Often help to modify prescribing practices of

physicians, usually resulting in decrease use.
Few study, particulary in term of reduction of
bacterial resistance
Programme should be well designed, and
implemented through a mixture voluntary,
persuasive or restrictive. Education,
production and dissemination of guidelines
is important. Audited regularly and feedback
provided both to users and programme
directors.If an audit indicates that voluntary
methods are not working, restriction may be
necessary

ANTIBIOTIC GUIDELINES

Demonstrate a commitment to rational

and prudent use of antibiotics
Policies should focus on using antibiotics
with the narrowest spectrum, which are
cheap, have minimal toxicity and have
the least impact on development of
resistance
The microbiology lab can assist through

Surveillance of bacterial resistance with reguler feed back

to prescibers
Restrict reporting of antibiotic sensitivities to narrow
spectrum agent, only reporting second and third line
antimicrobials when first-line will not work

NATIONAL ANTIBIOTIC POLICY

National level regulation of production

and import/local antibiotics
Prescribed only by doctors
Sufficient quantity
Ensure every hospital has access to
effective microbiology and infection
prevention and control services
Education
Written guidelines

HOSPITAL ANTIBIOTIC POLICY

Important initiatives are

1.The Antibiotic Committee.

Either stand alone or a part of the Drug and
Therapeutics Comm. The members should be:

Doctors
Nurses
Pharmacist
Microbiologist
Management
Inf control team
others

2.The antibiotic management team

Infectious diseases physicians

Clinical pharmacologists
Pharmacists
Clinical microbiologist
Others

3.Guidelines and protocols

List of antibiotics
Guideline for empiric and target
Protocol surgical prophylaxis
Should

different with treat

Protocol for evaluation of parenteral use

antibiotics, including stop-orders after 3-5 days
(depending on severity of infection) and
recommendation of sequential treatment
Protocol for reserve antibiotics
Should chosen according to local bacterial
resistance patterns

4.Education
Formal meeting
Clinical round
Provided by independent
professional outside the hospital
Not to be provided by pharmaceutical
industry

CONTROL of HEALTH CAREASSOCIATED INFECTIONS

Resistant bacterial strains are selected

in hospitals by excessive antibiotic use,
but may also enter a hospital when
patients come from another hospital,
community
Effective infection prevention and
control
Combination with effective antibiotic
policies

MINIMAL REQUIREMENTS FOR

HOSPITAL ANTIBIOTIC POLICY
1.

2.
3.

4.
5.

Antibiotic Committee producing a

hospital formulary and guidelines for
empiric and targeted therapy of
infection in the particular setting
Microbiology service in the hospital
Surveillance of antibiotic consumption
and antimicrobial resistance; regular
feedback to prescribers
Effective infection control programme
Education programme on antibiotic use
and consequence of antibiotic misuse

Concurrent Review Program Workflow Diagram

Daily Antibiotic
Reports Generated
Identify Patients
Requiring Potential
Intervention

Focused Patient
Record Review/
Computer
Record Review

No Intervention

Routine Intervention

Supplemental Strategies
Clinical Practice Guidelines
Pharmacodynamic dose
Optimization
Streamlining / De escalation
IV to Oral Therapy
Education

Additional Clinical
Input / Evaluation necessary

Recommendation/Educational
Note Left in a Non-Permanent
Fashion in the Patients Medical
Record OR Prescriber Contacted

IDSA / SHEA
Hospital Infections, 5th Edition, William R. Jarvis, 2007

Multidisciplinary involvement and core team members

Hospital
Epidemiologist

Hospital
Administrator
Infectious Diseases
Division

Infection
Control

Medical Information
Systems

Microbiology
Laboratory

ASP : Anti Microbial

Stewardship
Program

ASP Directors
ID PharmD
ID Physician

Clinical Pharmacy
Specialists

Decentralized
Pharmacy
Specialists

Director,
Research Dept

Chairman, P&T
Committee

IDSA / SHEA

Hospital Infections, 5th Edition, William R. Jarvis, 2007

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

Step 5: Practice antimicrobial control

Methods to Improve Antimicrobial Use

Passive prescriber education

Standardized antimicrobial order forms
Formulary restrictions
Prior approval to start/continue
Pharmacy substitution or switch
Multidisciplinary drug utilization evaluation (DUE)
Interactive prescriber education
Provider/unit performance feedback
Computerized decision support/online ordering

Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance
in Hospitals

Aims of Antibiotic Policy

Appropriate antibiotic usage

Optimal use and increase outcome
Cost effectiveness
Resistance Control

Control of Antibiotic
Usage

Avoid antibiotic homogeneity

Promote appropriate use of multiple drug
class
Apply formulary control and restrict of
specific agent or drug class that resistant
Consider antibiotic cycling, rotation or
mixed use of antibiotic classes
Develop and promote antibiotic guidelines
and protocol based on local data

Antibiotic Policy

Classification of antibiotics
Class A : Not restricted
Class B : Not restricted but 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
Cephalosporine
gen III
Fluoroquinolone
gen III-IV
Ertapenem

Vancomycin

Class C
Teicoplanin
Linezolide
Cefepime
Cefpirome
Ceftazidime
Pip-Tazo
Carbapenem
Tygecycline

Implementation
Antimicrobial Policy in
Hospital
Community

Hospital

Class A

Class A

Mild
WAR ModeratClass B
e Severe
D

Class C

Outpatient
Inpatient

ICU

Class B/C

Class C

Evaluation and
Surveillance
1.

Evaluate the quantity of antibiotic

usage

Retrospectively from the medical record

From medical prescription

Copy of prescription

2.

Evaluate the quality of antibiotic

usage

Using classification by Gyssens

Evaluation category of
Antibiotics Usage by
Gyssens
I.
II.

Correct Usage
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.
VI.

No Indication
Medical record is insufficient to be
evaluated

Surveillance of Antibiotic
Policy
Surveillance of every inpatient ward,
intensive care ward, and surgery room
periodically, e.g. monthly surveillance
in internal medicine ward
Report of surveillance periodically, e.g.
report of surveillance in internal
medicine ward every 6 months

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

Conclusion

Interaction between host- pathogen and

antibiotic should be considered in antibiotic
selection
Antibiotic factors: pharmacokinetic and
pharmacodynamic profile of the drug
Pathogen factors: susceptibility and
resistance pattern
Host factors: immunity status and
comorbidites
Strategy of antibiotic selection: antibiotic
for empirical, definite and prophylaxis

Conclusion

The implementation of antibiotic

policy is essential in every
hospital and health care to
promote:
rational use of antibiotics
cost-effective therapy
prevent microbial resistance