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FARMAKOLOGI :

ANTI-INFEKSI & KHEMOTERAPI :


1. ANTIVIRAL – ANTIBACTERIAL;

2. IRRASIONAL USE;
ADVERSE DRUG REACTION (ADR );
RESISTANCY ANTIBIOTICs;
DISINFECTANT-ANTISEPTIC;

3. ANTIFUNGALs; ANTIPARASITICs;

( 4. ANTICANCER & CYTOTOXIC).


Sulanto Saleh-Danu R. dr., SpFK.
Depart. Farmakologi & Terapi
Fak. Kedokteran – UGM;
Fak. Kedokteran – UKDW

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OBJEKTIF PERTEMUAN INI :
1. PEMAHAMAN, MENGERTI PENGGUNAAN
KHEMOTERAPI ANTIINFEKSI / ANTIBIOTIKA
SECARA BIJAK dan RASIONAL;
2. MENGERTI, MEMAHAMI, dan MEWASPADAI
RISIKO PENGGUNAAN YANG TIDAK BIJAK
MAUPUN TIDAK RASIONAL;
3. MENGERTI, MEMAHAMI dan MAMPU
MENDETEKSI SERTA MENCEGAH DAN
MENANGGULANGINYA AKIBAT DARI
PENGGUNAAN YANG TIDAK RASIONAL;
4. MENGERTI, MEMAHAMI dan MAMPU
MELAKUKAN PENCEGAHAN / PREVENTIF
PROFILAKSI DIRI TERHADAP INFEKSI.
ALUR PELAYANAN PESIEN
PASIEN PROSES YAN.KESEHATAN HASIL

KELUHAN; SEMBUH
SIGNs &
Proses Diagnostik ORGAN
BERFUNGSI
SYMPTOMs
Proses Terapi PUAS
BIAYA
TERJANGKAU
HARAPAN
KASUS

Sdr. Sakep, 35 tahun, datang pada saudara dengan keluhan


tidak enak badan, pusing (cekot-cekot), mual-muntah sudah
berlangsung sejak 2 hari ini.
Hari ini badan dirasakan demam, sesak nafas , batuk dan
muntah beberapa kali. BAB tidak ada gangguan.
Pemeriksaan Tekanan darah 120 / 80 mm Hg,
Nadi 88/menit reguler, suhu tubuh 39° C; jantung –paru dalam
batas normal , hepar lien tidak dijumpai kelainan, daerah/
area McBurney nyeri tekan namun tidak spesifik.

APA PROBLEM Sdr. SAKEP ???


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- Non-pharmacotherapeutics
- Pharmacotherapeutics

THERAPEUTIC
PROCESS

PHYSICIAN / Patients /
MEDICAL DOCTOR Clients

DIAGNOSTIC
PROCESS -Anamnestic
-Physical diagnosis
-Supporting diagnosis :
laboratories
radiologies
elektromedic, etc 4
PROSES TERAPI - RASIONAL
1. Penetapan
masalah pasien
6. Monitor hasil >
2. Penetapan
pengobatan
tujuan terapi

5. Penyampaian < 3. -Pemilihan obat


informasi yang tepat
4. Penulisan -Tindakan non
Resep obat yang tepat
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KASUS
Sdr. Sakep, 35 tahun, datang pada saudara dengan keluhan
tidak enak badan, pusing (cekot-cekot), mual-muntah sudah
berlangsung sejak 2 hari ini.
Hari ini badan dirasakan demam, sesak nafas , batuk dan
muntah beberapa kali. BAB tidak ada gangguan.
Pemeriksaan Tekanan darah 120 / 80 mm Hg,
Nadi 88/menit reguler, suhu tubuh 39° C; jantung –paru dalam
batas normal , hepar lien tidak dijumpai kelainan, daerah/
area McBurney nyeri tekan namun tidak spesifik.

R
SUBJEKTIF : OBJEKTIF :
-Tdk enak badan; -BP : 120/ 80 mm Hg
-Pusing (cekot-cekot) -Suhu : 39°C
-Mual-mutah -Lain-lain :
??
-Demam dalam batas normal
-Batuk

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RESEP DARI DR. DUL .
R/ PARASETAMOL 500 MG TABLT NO XV
S 3 dd 1
R/ HCl CODEIN 20 MG TABLT NO XV
S 2-3 DD 1
R/ BROMHEXIN TABLT NO XX
S 3-4 DD 1
R/ METOCLOPRAMIDE TABLT XV
S PRN MUAL MUTAH 2-3 DD 1 AC
R/ AMOXYCILLIN 500 MG NO. XX
S 4 DD 1 SAMPAI HABIS !
R/ MULTIVITAMIN CAPS NO XX
S 2 DD 1 PC

PRO : Tn Sakep ( 35 thn )


SUBJEKTIF : - Non-pharmacotherapeutics
-Tdk enak badan;
-Pusing (cekot-cekot) - Pharmacotherapeutics
-Mual-mutah
-Demam
-Batuk

SIMPTOMATIC ??
atau
THERAPEUTIC KAUSATIK ??
PROCESS ??
PILIHAN :
ANALGETIKA-ANTIPIRETIKA ?
NSAID ?
OBJEKTIF : ANALGETIKA OPIOID ?
-BP : 120/ 80 mm Hg ANTITUSIVE ?
-Suhu : 39°C EKSPEKTORANSIA ?
-Lain-lain : ANTIBIOTIKA ?
dalam batas normal ANTISPASMODIK ?
ANTIVOMITUS/MOTION SICKNESS ????
PILIHAN SAUDARA :

ANALGETIKA-ANTIPIRETIKA ?
NSAID ?
ANALGETIKA OPIOID ?
ANTITUSIVE ?
EKSPEKTORANSIA ?
ANTIBIOTIKA ?
ANTISPASMODIK ?
ANTIVOMITUS/MOTION SICKNESS ????

 Dari MASING-2 KLAS – TERAPI DIATAS :


OBAT PILIHAN UTAMA YANG MANA ?
CARA PEMBERIAN ? ORAL / PARENTERAL / lainnya ?
DOSIS PEMBERIAN ? FREKWENSI PEMBERIAN ?
LAMA (DURASI TERAPI) PENGGUNAAN ?
PERINGATAN-INSTRUKSI ?
What Is Rational Use of Drugs?

The rational use of drugs requires that


patients receive medicines appropriate to their
clinical needs, in doses that meet their own
individual requirements, for an adequate period
of time, and at the lowest cost to them and the
community. (WHO 1985)
 Appropriate indication
 Appropriate drug
 Appropriate administration, dosage,
and duration
 Appropriate patient
 Appropriate patient information
 Appropriate evaluation 13
Problems of
Medicine use in the community
• Incorrect choice of medicine due to incorrect “diagnosis”
• Stop using medicine due to different concept of cure
• Do not take medicine due to different concept of illness
• Incorrect dosage regimen
• Doing harmful medication because of incorrect knowledge
• Take unnecessary medicines because of promotion
• Purchasing expensive brandnames due to different value to
medicines
• Mis-interprete AE as another ailment
• Interaction with other medicines or food/beverage
• Use of counterfeit medicines
• Etc.
Irrational Use Pathology of
of Drugs Prescribing

•  The use of drugs when no drug therapy is


• indicated
•  The use of wrong drugs for a specific condition
requiring drug therapy
•  The use of drugs with doubtful or unproven
• efficacy
•  The use of drugs of uncertain safety status
•  Failure to prescribe available, safe, &
• effective drugs
•  Incorrect administration, dosages, or duration
Problems of Irrational Drug Use 15
Examples of Common
Inappropriate Prescribing Practices

• Overuse of antibiotics and antidiarrheals for


nonspecific childhood diarrhea
• Indiscriminate use of injections for malaria
• Multiple or over-prescription
• Use of antibiotics for mild, nonbacterial
infection, e.g., viral - ARI
• Tonics and multivitamins for malnutrition
• Unnecessary use of expensive
antihypertensives

Problems of Irrational Drug Use 16


Components of the Drug Use System

Local
Drug Imports Manufacture

The Drug Supply


Process

Provider and +
Consumer Behavior Private Physician or
Hospital or Pharmacist or
Other Practitioner
Health Center Drug Trader

Illness Patterns Public

Problems of Irrational Drug Use 17


Factors Underlying Irrational Use of
Drugs
Patients
Industry
• drug mis-
information • promotion
Prescribers • misleading Drug Regulation
• misleading
beliefs claims
• lack of education • availability of
• inability to and training
communicate non-essential
problems • lack of drug drugs
information Drug Supply • informal
• heavy patient load prescribers
• pressure to • inefficient
prescribe management
• generalization of • inavailability
limited beliefs of required
• misleading beliefs drugs
about efficacy

Problems of Irrational Drug Use 18


Impact of
Inappropriate Use of Drugs

Psychosocial
impacts

Risk of
unwanted
Waste of effects •patients rely on
Reduced resources unnecessary
quality of drugs
therapy
•adverse reactions
•reduced •bacterial resistance
availability
•morbidity
•increased
•mortality
cost
Problems of Irrational Drug Use 19
Penggunaan ANTIINFEKSI
 TIDAK RASIONAL
DAMPAK :

terjadinya resistensi mikroorganisme;

peningkatan adverse effects / organo-


toksisitas antibiotika/kemoterapetika;

biaya pengobatan menjadi lebih mahal;

kegagalan terapi infeksi.

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PATIENTS  COMMUNITY ACQUIRED INFECTION

HOSPITAL/
PRIVATE PRACTICE/
HEALTH CENTERS

HOSPITAL ACQUIRED INFECTION


( = NOSOCOMIAL INFECTION )

 COST CONSUMING
 PHARMACOTHERAPY:
more COMPLICATED
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MICRO ORGANISM/
PROBLEMS MICROBA./FUNGAL/
PARASITES
2

MICRO-ORGANISM
RESISTANT
HUMAN INCREASED

1 MO: growth & develop.


ANTIINFECTION: 3
-antibiotik
-antiprotzoa
-antifungal, etc. IRRATIONAL USE
NO NEW INFECTION OF
ANTIINFECTION ANTIINFECTION

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Other Drug Use Problems
• Incorrect treatment of malaria
 Incorrect use of chloroquin injection
• Poor compliance with TB therapy
 Causes treatment failure and resistant
organisms
• Underuse of effective drugs
 Hypertension
 Depression
• Hospital drug use problems
 Antibiotic misuse for surgical prophylaxis

Problems of Irrational Drug Use 23


SUPPORTING
PHYSICAL EXAMINATION
PATIENTS (LAB./RADIOL./
EXAMINATION
ELECTR MED.)

THERAPEUTICs
RESULT :
THERAPIES :
CURED  PHARMACOTHERAPY
NOT IMPROVED  NON-PHARMAC.THER.
WORST

MEDICATION ERRORs
ADVERSE PREDICTABLE REACTIONs
DRUG UNPREDICTABLE REACTIONS
REACTIONs ( ADRs)
MEDICATION ERRORs
 ADVERSE DRUG REACTIONs (ADRs)

PREDICTABLE REACTION :  effects pharmacological properties/activity


 rebound response upon discontinuation

UNPREDICTABLE REACTION :  Allergic effects


 Genetically – determined effects
 Idiosyncratic effects

INAPPROPRIATED USE
RESISTANCY
(LONG TERM PERIODE )
OF ANTIMICROBIALs
to ANTIBIOTIC
INAPPROPRIATE ANTI MICROBIAL USE :
1. PATIENTS AND COMMUNITY.
2. PRESCRIBERS AND DISPENCERS.
3. HOSPITALS.
4. USE ANTI MICROBIALS IN FOOD-PRODUCING
ANIMALS

1. PATIENTS and COMMUNITY :


 MISPERCEPTION
 SELF-MEDICATION
 ADVERTISING and PROMOTION
 ADHERENCE TO DOSAGE REGIMENS
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2. PRESCRIBERS and DISPENCERS :
 LACK OF KNOWLEDGE and TRAINING
 LACK ACCESS TO INFORMATION
 LACK OF DIAGNOSTIC SUPPORT
 FEAR OF CLINICAL BAD OUTCOME
 PERCEPTION OF PATIENTS DEMAND and
PREFERENCE
 ECONOMIC INCENTIVES
 PEER PRESSURE and SOCIAL NORMS
 PRESCRIBER’S WORKING
ENVIRONMENT
 LACK OF APPROPRIATE LEGISLATIONS
or ENFORCEMENT
 INADEQUATE DRUG SUPPLY
INFRASTRUCTURE
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3. HOSPITALS.
 INFECTION CONTROL
 CONTROL OF ANTIMICROBIAL USE
 HOSPITAL THERAPEUTICS COMMITTEES
 FORMULARIES
 CYCLING OF ANTIBIOTICS
 USE OF CLINICAL PRACTICE / TREATMENT
GUIDELINES
 INTEGRATED INTERVENTIONS
 CAPABILITY OF LABORATORY ( MICROBIOLOGY
and ANTIMICROBIAL RESISITANCE )
 INTERACTION BETWEEN THE HOSPITAL and
THE COMMUNITY
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4. USE OF ANTIMICROBIALS
IN FOOD-PRODUCING ANIMALS
 USE OF ANTIMICROBIAL AS GROWTH PROMOTERS
 USE OF ANTIMICROBIAL THAT AFFECT FOOD-BORNE
PATHOGENS ( Salmonella, Campylobacter spp.)

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FAKTOR MUNCULNYA BAKTERI RESISTEN
TERHADAP ANTIBAKTERIAL :

 EVOLUSI PADA BAKTERI


 PRAKTEK KLINISI dan
LINGKUNGAN YANG TIDAK /
KURANG BIJAK.

DAPAT TERJADI :
secara ALAMI
secara DIDAPAT
secara ALAMI : bakteri / mo belum pernah
terpapar antibakterial / antibiotika.

secara DIDAPAT (Acquired) :


sebelumnya sensitif terhadap
antibakterial, tetapi kemudian
setelah terpapar antibakterial
menjadi kebal / resisten terhadap
antibakterial tersebut..
ACQUIRED RESISTANCY :
 perubahan pada DNA bakteri
MUTASI : perubahan genetik secara spontan.
Pada populasi bakteri terdapat
mutan yang resisten terhadap
antibakterial, ketika bagian yang
peka dihancurkan antibiotika,
Bagian yang resistent multiplikasi.

TRANSFER MATERIAL GENEs.


Bakteri mempunyai material genetik
ekstrachromosomal (plasmid) pada
sitoplasmanya. Plasmid yang
menyandang faktor R , bila terkirim
ke bakteri lain timbul resistensi pada
bakteri yang menerima.
TRANSFER MATERIAL GENEs
(plasmid / faktor-R).

TRANSDUKSI  plasmid DNA ditransfer melalui


bakteriophage

TRANSFORMASI  bakteri yg resisten melepas


faktor-R pada media
yang ditangkap oleh
bakteri lain

CONJUGASI  faktor-R ditransfer antar sel


bakteri dengan kontak
langsung melalui jembatan
( sex pilus )
bakteri
normal
Plasmid
mutan dengan
resisten faktor -R

bakteri transfer
rusak : plasmid
Mutan
resisten
tidak rusak

TRANSFER MATERIAL GEN


Masuk ke bakteri
lain  resisiten ( PLASMID –dengan Faktor-R )
TRANSFER :
 TRANSDUKSI
 TRANSFORMASI
MUTASI  CONJUGASI
RESISTENSI BAKTERI :
(Ria,L B. & Bonomo, R.A., 2007)

Berdasarkan GENETIC :
MUTASI dari GENETIK SELULER;
Mendapatkan GENETIK yang RESISTEN
MUTASI dari GENETIK RESISTEN yang
didapat (acquired)
Berdasarkan MEKANISME BIOKIMIAWI :
- MODIFIKASI dari ANTIBIOTIKA
- MODIFIKASI dari MOLEKUL SASARAN /
TARGET MOLECULE
- RESTRICTED ACCESS to THE TARGET
- EFFLUX PUMPs
PERKEMBANGAN RESISTENSI BAKTERI
 ANTIBAKTERIAL :

1. RESISTENSI KARENA OBAT YANG MENCAPAI /MASUK KE BAKTERI TURUN


2. RESISTENSI KARENA OBAT DIKELUARKAN ( DRUG EFFLUX ) ;
 Multidrug And Toxic compound Extruder ( MATE )
 Mayor Fascilitator Superfamily ( MFS ) transporter
 The Small Multidrug Resistance ( SMR ) system
 The Resistance Modulation Division ( RND ) exporter
 ATP Binding Cassette ( ABC ) transporters.
3. RESISITENSI KARENA DESTRUKSI /PERUSAKAN ANTIBAKTERIAL
4. RESISITENSI KARENA BERKURANGNYA AFINITAS OBAT PADA SEL TARGET
5. INKORPORASI DARI OBAT
6. RESISTENSI KARENA ENHANCED EXCISION of INCORPORATED DRUG
7. HETERO-RESISTANCE & VIRAL Quasi Spacies.
PENCEGAHAN TERJADINYA RESISITENSI
TERHADAP ANTIBAKTERIAL :

1. ANTIBAKTERIAL / ANTIBIOTIKA DIGUNAKAN


BILA MEMANG DIPERLUKAN
( INDIKASI & RISIKO INFEKSI BAKTERIAL );

2. PEMILIHAN dan PENGGUNAAN ANTIBIOTIKA


SECARA BENAR;

3. DOSIS TEPAT; CARA PEMBERIAN dan


DURASI YANG BENAR;

4. PENGGUNAAN TERAPI KOMBINASI


YANG BENAR
DISINFECTANTS
ANTISEPTICS
STERILANTS

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DISINFECTANTS : ZAT KIMIA YANG MENGHAMBAT / MEMBUNUH
MIKROORGANISME

ANTISEPTICS : DISINFECTANT YANG MEMPUNYAI TOKSISITAS RELATIF RENDAH


UNTUK SEL HOST DAN DIGUNAKAN SECARA LANGSUNG PADA
KULIT, MUKOSA ATAU PADA PERLUKAAN

STERILANTS : BILA DIGUNAKAN DENGAN KONSENTRASI TERTENTU DAN


LAMANYA PENGGUNAAN PADA BENDA-2 DAPAT
MEMBUNUH BENTUK VEGETATIF MAUPUN SPORA

ANTISEPSIS : PENGGUNAAN ANTISEPTIK PADA JARINGAN HIDUP UNTUK PREVENSI


TERHADAP INFEKSI

DECONTAMINASI : DESTRUKSI ATAU PENGURANGAN JUMLAH / AKTIFITAS


MIKRORGANISM

STERILISASI : PROSES INTENSIF MEMBUNUH ATAU MENGHILANGKAN SEMUA


BENTUK MIKRORGANISM (VEGETATIF, SPORA, VIRUS.

PASTEURISASI : SUATU PROSES YANG DAPAT MEMBUNUH MIKROORGANISM


YANG NONSPORULATING DENGAN AIR / UAP PANAS ( 65-100⁰C)
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MEKANISME KERJA ANTISEPTIC ( GERMICIDE )

1. OKSIDASI PROTOPLASMA BAKTERI


2. DENATURASI PROTEIN BAKTERI
3. AKSI SEPERTI DETERGENT
4. KOMPETISI DENGAN SUBSTRAT ESENSIAL ENZYM UTAMA
SEL BAKTERI

FAKTOR YG MEMPENGARUHI AKTIFITAS GERMISIDE :

 KONSENTRASI dan LAMANYA KONTAK DENGAN BAKTERI


 KEPEKAAN BAKTERI : spora dan Virus banyak yang resisiten.
 TEMPERATUR : makin naik temperatur makin kuat potensi
antiseptik
KLASSIFIKASI :

1. ASAM : asam borat; asam benzoat


2. ALKOHOL : ethanol; isopropyl alcohol
3. ALDEHYDE : formaldehyde; glutaraldehyde
4. SURFACTANTs : sabun;benzalkonium; cetrimide;
cetylpyridinium chloride; dequalinium chloride;
5. DERIVAT PHENOLs : phenol; cresol; resorcinal;
chlorhexidine;chloroxylenol; hexachlorophene;
6. HALOGENs: iodine; iodophors; chlorine;chloramines;
7. OXIDIZING AGENTs : hydrogen peroxyde;
benzoylperoxyde; potasium permanganate;
8. DYEs : gentian violet; methylene blue; brilliant green;
acriflavine; proflavine;
9. GARAM LOGAM : perak nitrat; zinc compounds;
mercurial compounds
BAKTERI VIRUS LAINNYA+
GR + GR - BTA SPORA Lipophil. Hidrophil. Fungi Cyst Prions

Alkohol (isopro- HS HS S R S V -- -- R
panol,ethanol)
Aldehyde HS HS MS S (lbt) S MS S -- R
(formaldehyde)
Chlorhexidine HS MS R R V R -- -- R
gluconate
Na hypochloride, HS HS MS S S S MS S MS
chlorine dioxide (pH 7.6) (high conc.) (high conc.)
Hexachlorophene S(lbt) R R R R R R R R
Povidone, iodine HS HS S S S R S S R
(high conc.)
Phenols, HS HS ± R S R -- -- R
quaternary
ammonium comp.
Strong oxidizing HS MS- R R R S R R R R
agents, creosol

HS=high susceptible; S=susceptible; MS=moderate susceptible; R=resistant; V=variable; -- =no data


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TOPIK :
FARMAKOLOGI ANTI-
INFEKSI - 3.

ANTIFUNGALs
ANTIPROTOZOAs
ANTIPARASITEs
ANTHELMENTIKs KATZUNG,BG., (eds.)
2012, BASIC AND
CLINICAL
PHARMACOLOGY , 12TH
Ed., Lange-McGrawHill.,
Boston.

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DAFTAR REFERENSI.

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Churchill Livingstone, Delhi
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McGrawHill.
3. NEAL, M.J., (2006), Medical Pharmacology at Glance, 5th Ed., Blackwell
Publishing
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1st Ed.,MedMaster, Inc., Miami, FL
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Comparasion, St Louis.
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The Pharmacological Basis of Therapeutics, 12th Ed.
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48th Ed.,McGrawHill
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