The Potential Risk of MDRO in

Health Case Facility

Kuntaman
KPRA Kementerian Kesehatan R.I.
Depart. of Clinical Microbiology
Faculty of Medicine Airlangga University/
Dr. Soetomo Hospital Surabaya Indonesia
kuntaman@fk.unair.ac.id, 08113410352

Seminar PPRA
MoH, Jakarta, 17 Juli 2017 1
 Learning Objectives

The Emergene and Spread of AMR

Risk of MDRO in Health Care facility
Basic concept of Prudent Use of AB
The Services on Clinical Microbiology

2
 Case-1
Day-1 (3/7/2017): Female, 35 y.o.
Referred from Sec Hosp to Dr Soetomo;
Sectio-aesarian: 32 days ago
Post-sectio Caesarian Septic, Temp. 38 C
2 weeks Post-SC: Wound Infection
Ther: CTX CRO 3 x 1 gram & Metro
RSDS:
Lab: Hb = 10 mg/dl, Leu = 16.000/dl
SK = 0.43; SGOT/PT = 9/9
Swab of Wound Inf send Lab Micro 3
 Case-1
Day-2:
USG: Pocket abscess, para-iliacal, 300 ml

Therapy: CRO & GEN & METRO

Day-3:
Leuco: 21.000
Culture: K. pneumonia-ESBL
Sens: AK, MEM, PTZ
4
 Case-1
Day-4: Consult Clin Microb
S: Pts + Septic;
O: Wound Inf; PCT=0.7
CT-Scan: Pocketed Abscess, Posterior Uterus;

A: Sepsis Post-SC, Wound Inf ESBL, Intra-perit

(Pocket) abscess

P: AK,
Source Control: Abscess: ?? Location ??
5
 Case-1
Day-5: Re-open, exploration
Post-SC, Abscess 750 ml, Omentum Adhesive
Washing cav abdomen (Digestive Surgeon);
Drain: Para-colica & Cav Douglass
-Culture: Pus, Tissue,
Day-8:
A: Sepsis going better
1. K pneu ESBL: Sens AK, MEM, PTZ
2. Streptococcus anginosus; Sens: no-result

P: MEM
6
 Management the patients
Clinical Problem
Septic Post-SC 30 days: ??
Immuno-compromise
Microbiology problem
Wound Infection (Surgical Site Infection)
Intra-abdominal abscess
Multiple bacterial infection with MDRO-ESBL: Was
not detected in Sec Hosp
Thx: CRO/CTX: is a nutrition (not AB) for ESBL-
Fast-result of Micro Lab was needed
Clin Microb Interpretation was required
7
Resistance Development &
Risk Factor

9
 Resistance Development
Case-1: RISK
1. Antibiotic 1.AB
2. Standard Precaution 2.
3.Skill &
3. HCW of 4 Pillars:
Know &
a. Skill & Knowledge Behavior
b. Behaviour
4. Facilities 4. Facilitie
5. Policy 5. Hosp. Policy
10
 AMR Driven
Selection Pressure
Irrational use of AB
Quantity of AB: is very important
Transmission/Spread
Among patients
Among microbes

11
Selection

12
13
Transmission

14
15
 Air
Droplets
Contact
Water
Food
Blood
Vectors

16
 Resistance against Amoxicillin
First Line AB Co-trimxazole

Up to 100% Clinical Isolates

RSU Dr. Soetomo 2014

E coli Klebsiella spp

AML10 = 100% AML10 = 100%
SXT = 80% SXT = 70%
WHO Global Strategy for
containment of antimicrobial
Resietance. 2001
17
 2ND/3RD Cefotaxim
Line AB Cefepim
Ciprofloxacin

Clin Isolates
Res increase up to 2014
RSU Dr. Soetomo 2008
non-effective usage
E coli
coli Acineto
Klebsiella
Kleb pneumo
baum
spp
CTX = 56 CTX CTX
= 94%= 64
CTX30 = 46% CTX30 = 70%
FEP = 58FEP FEP
= 84%= 62
FEP30 = 18% FEP30 = 32%
MEM = MEM
2 = 63%= 13
MEM
CIP5 = 60% CIP5 = 47%

18
 Overuse
Pada infeksi ringan

Emerging and
Misuse Abuse of AB
Tidak ada sarana spread of
Diagnostik
AMR M.O.

Underuse

20
 Extended Spectrum Beta Lactamases
(ESBLs) Producers
as a Model of Surveillance

(Kuntaman et al, WHO Project, 2013)

ESBL
- B-Lac-ase Extended spectrum to 3rd gen
Ceph (& others)
- Res against: 3rd, 4th Gen Ceph
- Co-resistance to CIP
- Plasmid mediated
21
 AB
Development
India (Mathai et al, 2002)
K pneumo = 61%
E coli = 55%
ESBL producing
RSU
RSUDS DS20092013
bacteria KKpneumo
pneumo==24% 34%
EEcoli
coli ==20%
41%
CTX30
CRO30
CAZ30
Spain (Canton et al, 2002) FEP30
K pneumo = 0.3%
E coli = 4.8%
ESBL 1985 2009
2013
Waktu

22
 BAGAIMANA INDONESIA
RSUD.Dr. Soetomo 204
The prevalence of ESBL producing E.coli and
Klebsiella pneumoniae among hospitals in sample kasus
Indonesia six hospitals 2013 Jan-Juli 2010
N= 554
60 56,39% 56,8% 100.00%
51,69% 52,23% 90.00%
50 45,33% 80.00%
40,83% 70.00%
40 37,82% 60.00%

Persentase
34,31% 32,16% 32,7% 35,02
50.00% %(194)
30 27,94% 26,71% 40.00%
30.00%
20 20.00% 6,50%(36) 4,51%(25)
10.00%
10 0.00%
Jumlah Isolat Jumlah ESBL Jumlah PAN Jumlah
RESISTEN MRSA
0
Macam Isolat

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KEMENTRIAN KESEHATAN
 Table. Antibiotic susceptibility (n) pattern of
ESBL producing E.coli
RSDS RSSA RSDM RSDK RSSD RSP TOTAL
Cefotaxime 0.17 0.00 NA 1.57 3.31 NA 0,78
Ceftriaxone 0.00 0.00 2.62 5.93 NA 0.00 1,19
Ceftazidime 0.17 0.00 12.07 4.19 8.33 0.00 3,83
Cefepime 0.34 42.06 26.21 9.42 25.62 0.00 12,78
Ciprofloxasin 16.10 29.37 10.00 18.32 7.50 10.42 15,21
Amikacin 97.95 95.24 82.99 96.34 73.33 98.96 92,4
Gentamycin 61.43 69.05 62.15 10.99 56.30 63.54 55,12
Fosfomycin 92.86 100.00 NA 78.57 82.89 NA 90,85
Piperacillin-
49.57 76.19 NA 76.44 65.81 66.67 60,4
tazobactam
Cefoperazone-
53.85 NA 83.33 72.73 57.98 15.63 57,08
sulbactam
Meropenem 99.83 98.41 98.96 95.29 94.96 100.00 98,51
Levofloxacin 20.14 29.37 9.00 21.48 15.38 10.42 17,66
Tigecyclin 78.08 99.21 97.92 99.48 40.63 100.00 94,67

Data surveillance PPRA RSDS-Balitbangkes-WHO 2013 24

ESBL PRODUCING
BACTERIA

PREVALENCE of ESBL in INDONESIA

survei
llance
2016
45-
WHO/ 89%
PPRA
26-
RSD 56%
RSD S
S
AMRI
PPRA sd saat ini Fokus PPK-3;
N

PPK-2,: ??? Sumber: ???

 Antibiotic Use
Dr. Soetomo Hospital Surabaya,
April July 2011

Surg Psychi ICU

Ward Ward Ward
Patients 47 47 13
26
Patient-Days 1160 1597 241
DDD Total AB 726.56 22 905.27

DDD/100 Pts-Days 62.64 1.38 375.63

 Resistance Pattern (%)
E coli Gut Flora
Dr. Soetomo Hospital Surabaya,
April July 2011

AMP CTX CRO TE MEM AK CIP

SURG 97.5 75 70 83 0 23 70
(40)
Psych 100 2 2 38 0 2.1 4
(47)
ICU 100 61.5 37 92.3 0 23 76.9
(13)

27
 MDR (%)
E coli Gut Flora
0 1 2 3 4 5 6 Total
MDR
SURG 3 3 7 6 13 8 37
(40) (92.5%)
Psych 23 13 9 1 0 1 0 11
(47) (23.4%)
ICU 0 3 2 1 7 0 13
(13) (100%)

(MDR Res of 3 AB Class)

28
 Surveillance 2016, MoH
8 Academic Hosp in Indonesia
Prudent Use: ??
Health Services of Dept.X: [n Pts: 150]
Hosp AB Use AB & No 3rd Gen
Indication Ceph
1 6.7% 40% 10%
2-13
14 86.96% 90% 22%

SiapaKita
yangSemua
salah: ??? 30
 The Principles Diagnosis of Infection
Inappropriate Diagnosis Abuse AB AMR

31
 Diagnosis

Sepsis
Model (Mandell, 2004)

SIRS Systemic Inflammatory

Response Syndrome

Source of infection
32
 Sepsis (Mandell, 2004)

SIRS 1. Temp >= 38 C (Rect); 37.8 C (Ax)

< 36 C
2. Pulse > 90/mnt
>=2
3. Resp > 20/mnt or P O2 < 32 mmHg/l
4. Leucocyte > 12 million/ml
< 4 million/ml
> 10% Cell Immature
Source of infection Find out Culture
Bacteremia
Lung (pneumonia)
Bladder (UTI)
Intestine (Gastroenteritis) etc 33
 Shock Septic
SOFA (Sequential Org Fail Assestment)
Vascular disturbance: Blood Pressure ??
Organ disturbance/disfunction: Renal/Liver
function ??
Lactate accumulation

The Basic concept of Prudent Use of

antimicrobial drug 34
 Case-2: Therapy ??
Male, 78 yrs old
Ventilator
Productive sputum send to Micro
Lab
Klebsiella pneumoniae, ESBL (+):
S: AK, CRO, MEM, FOS
Clinical Interpretation:
Sepsis ?? Leucocyte: ??
Thorax Photo
Therapy: Antibiotic ??
35
Case-2
M, 78 y.o, Respirator (+),
Tem. 38.5 C, WBC: 16.000/ml
Diag: VAP

36
Micro-Lab Result ??? Less/Equal to 3 days
Klebsiella pneumoniae ESBL+
Antibiotic Res pattern
Ampicillin R
Cephalotin R
Gentamicin R
Amikacin S
Amox-Clavulanic R
Cefotaxime R
Ceftriaxone S
Cefepim R
Ciprofloxacin R
Co-trimoxazole R
PTZ S
Meropenem S
37
HCW Risk Factor AB Abuse AMR

The Services on
Clinical Microbiology

38
The Services on Clinical Microbiology

1. First Level:
OLD Indonesian Clin Micr Services ?
- Laboratory base services/Lab Expert
- Technical aspect
2. Second Level:
Consultative & Interpretation of Micro Lab
Result

3. Third Level: Infection Management &

Difficult Case on Infection
Finch et al, 2005
39
 Gram Stain
can suscessfully
Narrowing therapy in 50% Cases
J. Clin. Path., 97;50:1010-12
Clin. Inf. Dis., 98;27:478-86

Without direct consultation, recommendation

are followed in 39% cases
Because the clinician will not change based on a
report alone

Diagn. Micro.Infect.Dis, 91;14:157-66

40
 Kita Butuh SATU Pilar lagi
Spesialis Mikrobiologi Klinik
Share dgn Klinisi PPK-3: ??
Support: PPK-2: ??
Aspek Teknis Pemeriksaan Mikrobiologi
Interpretasi Hasil Pemeriksaan Mikrobiologi
Managemen Pasien Infeksi (Seriously Infection)
Hospital Policy di bidang: Infeksi & AMR &
Antibiotik
Optimal: 1 SpMK di setiap 150-250 Beds
41
Summary
1. Penanganan kasus infeksi (berat) di
Faskes Sekunder, perlu perhatian khusus;
sejalan meningkatkan efisiensi
2. Miss-Management kasus infeksi akibat:
1. Pengetahuan & Ketrampilan
2. Perilaku
3. Fasilitas
3. Antibiotika: obat vs Nutrisi
42
Summary
4. Kasus infeksi ringan, mudah diatasi;
single dokter;
5. Kasus infeksi berat: perlu kerjasama antar
profesi
6. Resiko utama Resisten:
a) AB: Kuan, Kual
b) Pengetahuan & Ketrampilan HCW
c) Fasilitas
d) Kebijakan 43
Summary
7. Pilar penting pengendalian AMR :
Pelayanan Klinik (Clinician/s)
Pelayanan Mikro Klinik (Clin Microb-gist)
Pelayanan Farmasi (Pharmacist)
Tim PPI
8. Pelayanan Mikro Klinik bisa mendukung:
o Interpretasi hasil Lab
o Diagnosis infeksi definitif
o Terapi Infeksi: AB vs Non-AB
o Rasionalitas terapi vs Biaya
9. Penyediaan SpMK 1/150-250 beds bisa
meningkatkan kinerja pelayanan penyakit infeksi
44
East Java Health Office 2015

Thank you for your attention 45