DAFTAR RIWAYAT HIDUP

• Nama : Hindra Irawan Satari

• Posisi :
Divisi Penyakit Infeksi dan Pediatri Tropis, Departemen IKA, FKUI-RSCM
Ketua, Pokja Pencegahan Pengendalian Infeksi, KemenKes RI, 2018-sekarang
Ketua, Pengurus Pusat Perkumpulan Pengendalian Infeksi (Perdalin), 2017-sekarang
Anggota, Komite Pengendalian Resistensi Antimikroba, KemenKes RI, 2017-sekarang
Anggota, Tim Pencegahan Pengendalian Resistensi Antimikroba, RSCM, 2007-sekarang
Ketua, Komite Pencegahan dan Pengendalian Infeksi (PPI) RSCM,2007-2017

Pendidikan
– Dokter, FK UNPAD, 1981
– Spesialis Anak, FKUI, 1992
– Master of Tropical Pediatrics, School of Tropical Medicine, Liverpool University, United
Kingdom 1995
– Konsultan, Penyakit Infeksi Tropis, Kolegium IDAI, 2002
– Doktor, FKUI, 2012

• Email: hsatari@ikafkui.net
 RELATION OF INFECTION CONTROL IN
ANTIMICROBIAL RESISTANCE PROGRAM
Hindra Irawan Satari
 OUTLINE
• Background
• Health-care associated infection (HAIs)
• PCI program
• Antimicrobial resistance program
• Conclusion
 BACKGROUND

– Health care–associated infections : 4.0% ( 95% CI, 3.7

to 4.4).
– The most common types were
• pneumonia (21.8%),
• surgical-site infections (21.8%),
• gastrointestinal infections (17.1%).
– Clostridium difficile (commonly reported pathogen):
12.1%.
– Device-associated infections (i.e., c-c–a bsi, c-a uti, and v-a p):
25.6%
– Estimated: 721,800 HAIs in U.S. acute care hospitals in
2011.
• Multistate Point-Prevalence Survey of Health Care–Associated Infections (HAIs)
– Shelley S. Magill, M.D., Ph.D., Jonathan R. Edwards, M.Stat., Wendy Bamberg, M.D., Zintars G. Beldavs, M.S., et al
– Engl J Med 2014; 370:1198-1208
 OUTLINE
• Background
• Health-care associated infection (HAIs)
• PCI program
• Antimicrobial resistance program
• Conclusion
 HEALTH-CARE ASSOCIATED INFECTIONS (HAIs)

• Healthcare-associated infections (HAI) are defined as

infections not present and without evidence of incubation
at the time of admission to a healthcare setting.

• As a better reflection of the diverse healthcare settings

currently available to patients, the term healthcare-
associated infections replaced old ones such as nosocomial,
hospital-acquired or hospital-onset infections

•
INFECTION CONTROL SHARE INTER-
INTER-RELATIONSHIPS
WITH QUALITY AND PATIENT SAFETY

PATIENT
SAFETY

INFECTION PREVENTION QUALITY

CONTROL
 ORGANIZATION
STRUCTURE President Director

Dep/Unit/Instalation PPIRS Committee

Secretary

IPCN Members

IPCO/IPCN – Link
Dep/Unit/Instalation/Ward
 PCI Responsibilities..
2.Medical Equipment, Devices, and Supplies
The hospital reduces the risk of infections associated with
medical/surgical equipment, devices, and supplies by ensuring adequate
cleaning, disinfection, sterilization, and storage; and implements a
process for managing expired supplies.
The hospital identifies and implements a process for managing the reuse
of single-use devices consistent with regional and local laws and
regulations.
 PCI Responsibilities..
3.Infectious Waste
The hospital reduces the risk of infections through proper
disposal of waste.
The hospital implements practices for safe handling and
disposal of sharps and needles.
4.Food Services
The hospital reduces the risk of infections associated with the
operations of food services.
5.Construction Risks
The hospital reduces the risk of infection in the facility associated
with mechanical and engineering controls and during demolition,
construction, and renovation.
 PCI Responsibilities..
6. Transmission of Infections
The hospital provides barrier precautions and isolation procedures
that protect patients, visitors, and staff from communicable
diseases and protects immunosuppressed patients from acquiring
infections to which they are uniquely prone.
The hospital develops and implements a process to manage a
sudden influx of patients with airborne infections and when
negative-pressure rooms are not available.
The hospital develops, implements, and tests an emergency
preparedness program to respond to the presentation of global
communicable diseases.
Gloves, masks, eye protection, other protective equipment, soap,
and disinfectants are available and used correctly when required.
 PCI Responsibilities..
7. Quality Improvement and Program Education
The infection prevention and control process is integrated with the
hospital’s overall program for quality improvement and patient
safety, using measures that are epidemiologically important to the
hospital.
The hospital provides education on infection prevention and control
practices to staff, physicians, patients, families, and other caregivers
when indicated by their involvement in care.
 ISOLATION PRECAUTION APPLICATION
STANDARD PRECAUTION
• Hand hygiene
• Personal Protective Device 1. Contact: MRSA
• Sharp and waste management 2. Dropplet: Pneumonia
• Patient placement (Isolation/
cohort) 3. Air bone: TBC
• Health Environment
• Linen Manajement
• Decontamination and
sterilisation
• Health-care worker safety
• Lumbal punction procedure
• Cough Etiquette
• Safety injection
MANUAL BOOK MANAJERIAL AND GUIDANCE PCI
RSCM

2011 (4th edition) 2015 (5th edition)

 HAIs Surveillance
RSCM
• Blood stream infection (BSI)
• Surgical site infections (SSI)
• Catheter-associated urinary tract infections (CAUTI)
• Catheter–related bloodstream infections (CRBSI)
– Central
– Peripher
• Pneumonia
– Ventilator-associated pneumonia (VAP)
– Hospital-Acquired pneumonia (HAP)
• Decubitus
• Needle stick injury
• Hand hygiene compliance
• Outbreak surveillance
 MELAKSANAKAN SURVEILANS HAI’S

INSIDEN RATE INFEKSI ALIRAN DARAH TERKAIT PEMASANGAN INSIDEN RATE PLEBITIS TERKAIT PEMASANGAN IVL DI RSCM TAHUN
CVL DI RSCM TAHUN 2008- SEMESTER I 2017 2008-SEMESTER I 2017
∑kejadian infeksi/∑hari pemasangan CVL x 1000

∑kejadian infeksi/∑ hari pemasangan IVL x 1000

120.00
25.00 23.06
100.00 96.03
20.00
80.00 Insiden rate(‰)
15.00 Insiden rate(‰)
60.00 Target <3.5‰
(‰)

Target <1‰

(‰)
10.00
40.00
3.40
20.00 5.00 1.66 1.08 0.82
5.37 7.40 5.49 5.18
4.08 4.61 5.82 2.00 1.63 0.27 0.26 0.09 0.07 0.02
0.00 0.31 0.00

TAHUN
TAHUN

INSIDEN RATE HOSPITAL ACQUIRED PNEUMONIA DI RSCM TAHUN

INSIDEN RATE VENTILATOR ASSOCIATED PNEUMONIA DI RSCM
2.79 2008-SEMESTER I 2017
∑kejadian infeksi/∑hari pasien Frah baring x 1000

TAHUN 2008- SEMESTER I 2017

∑KEJADIAN INFEKSI/∑PEMASANGAN VENTILATOR

3.00
2.49 35.00
2.50 2.27 31.40
30.00
2.00 1.25 Insiden rate(‰) 25.00
1.50 20.00 Insiden rate(‰)
X 1000 (‰)

Target <1‰ 15.80 15.52

13.66
(‰)

0.91 15.00 Target <5.8‰

1.00
0.43 0.37 10.00 6.31
0.50 0.25 0.18 0.18 3.68 3.40
5.00 1.40 2.18 1.97
0.00 0.00

TAHUN
TAHUN
 MELAKSANAKAN SURVEILANS HAI’S

INSIDEN RATE INFEKSI ALIRAN DARAH TERKAIT PEMASANGAN INSIDEN RATE PLEBITIS TERKAIT PEMASANGAN IVL DI RSCM TAHUN
CVL DI RSCM TAHUN 2008- SEMESTER I 2017 2008-SEMESTER I 2017
∑kejadian infeksi/∑hari pemasangan CVL x 1000

∑kejadian infeksi/∑ hari pemasangan IVL x 1000

120.00
25.00 23.06
100.00 96.03
20.00
80.00 Insiden rate(‰)
15.00 Insiden rate(‰)
60.00 Target <3.5‰
(‰)

Target <1‰

(‰)
10.00
40.00
3.40
20.00 5.00 1.66 1.08 0.82
5.37 7.40 5.49 5.18
4.08 4.61 5.82 2.00 1.63 0.27 0.26 0.09 0.07 0.02
0.00 0.31 0.00

TAHUN
TAHUN

INSIDEN RATE HOSPITAL ACQUIRED PNEUMONIA DI RSCM TAHUN

INSIDEN RATE VENTILATOR ASSOCIATED PNEUMONIA DI RSCM
2.79 2008-SEMESTER I 2017
∑kejadian infeksi/∑hari pasien Frah baring x 1000

TAHUN 2008- SEMESTER I 2017

∑KEJADIAN INFEKSI/∑PEMASANGAN VENTILATOR

3.00
2.49 35.00
2.50 2.27 31.40
30.00
2.00 1.25 Insiden rate(‰) 25.00
1.50 20.00 Insiden rate(‰)
X 1000 (‰)

Target <1‰ 15.80 15.52

13.66
(‰)

0.91 15.00 Target <5.8‰

1.00
0.43 0.37 10.00 6.31
0.50 0.25 0.18 0.18 3.68 3.40
5.00 1.40 2.18 1.97
0.00 0.00

TAHUN
TAHUN
 SURVEILANS HAI’S RSCM
2008-SEMESTER I 2017

INSIDEN RATE INFEKSI SALURAN KEMIH TERKAIT

INSIDEN RATE INFEKSI DAERAH OPERASI DI RSCM TAHUN
PEMASANGAN CATETER URINE MENETAP DI RSCM TAHUN
2008- SEMESTER I 2017
2008-SEMESTER I 2017
∑kejadian infeksi/∑ hari pemasangan kateter urine x 1000 (‰)

∑kejadian infeksi/∑operasiL x 100 (%)

6.00
2.50
4.81
5.00
3.92 2.00 1.95
4.00 Insiden
rate(‰)
1.50 1.44
3.00 Target <4.7‰ Insiden
1.24 rate(%)
1.76
2.00 1.44 1.00 0.96 1.00 1.00 Target <2%
0.68 0.72
1.00 0.61 0.62
0.36 0.22 0.21 0.50
0.07 0.43
0.33
0.00
0.00

TAHUN

TAHUN
 KEPATUHAN KEBERSIHAN TANGAN RSCM
2011- SEMESTER I 2017

KEPATUHAN PETUGAS MELAKUKAN KEBERSIHAN TANGAN KEPATUHAN PENGUNJUNG MELAKUKAN KEBERSIHAN TANGAN
PETUGAS DI RSCM TAHUN 2011-SEMESTER I 2017 DI RSCM TAHUN 2012-SEMESTER I 2017
tangan/∑kesempatan melakukan kebersihan tangan

∑pengunjung yang patuh dalam kebersihan

100.0% 90.0%
90.0% 86.4% 87.9%
87.9% 85.0%
∑kepatuhan melakukan kebersihan

80.0%
82.4%

tangan/∑petugas (%)
70.0% 76.7% 76.2% % Kepatuhan 80.0% 82.2%
60.0% 70.2% 72.7%
76.6% 77.9% % Kepatuhan
50.0% Target > 85% 75.0%
Target > 85%
(%)

40.0% 72.2% 71.8%

30.0% 70.0%
20.0%
65.0%
10.0%
0.0%

TAHUN
TAHUN
 KEPATUHAN PEMAKAIAN APD RSCM, 2015-SEMESTER I 2017 &
KEJADIAN TERTUSUK BENDA TAJAM RSCM, 2011-SEMESTER I 2017

KEPATUHAN PEMAKAIAN ALAT PELINDUNG DIRI DI RSUPN JUMLAH KEJADIAN PEGAWAI TERTUSUK BENDA
DR.CIPTO MANGUNKUSUMO TAHUN 2015-SEMESTER I 2017 TAJAM/TERPAJAN CAIRAN TUBUH DI RSCM TAHUN 2011 -
SEMESTER I 2017
98.5% 80 76 75
98.0% 98.0%

∑ kejadian
97.5% 60 44 52
%KEPATUHAN

97.0%
96.5% 96.6% %KEPATUHAN 40 46
96.0%
95.5% Target ≥97% 20 37
15
95.0% 95.2%
0
94.5%
94.0% 2011 2012 2013 2014 2015 2016 JAN-JUN
93.5% 2017
2015 2016 JAN-JUN 2017
TAHUN
TAHUN
+ BACTERIAL AND ANTIBIOTICS
SUSCEPTIBILITY PROFILE IN RSCM

• 2009-2012
 CONTENTS
• General profile of bacterial and antibiotic
susceptibility at RSCM
– Out patient
– In patient
• Source of specimens
– Out patient
– In patient
• MRSA, ESBL, Pan-Resistant bacteria
 OUTLINE
• Background
• Health-care associated infection (HAIs)
• PCI program
• Antimicrobial resistance program
• Conclusion
INFECTION CONTROL SHARE INTER-
INTER-RELATIONSHIPS
in controlling infectious diseases in RSCM

Four pillars
1. Hospital infection Committee (Pencegahan &
Pengendalian Infeksi Rumah Sakit /PPIRS)
2.Pharmacology clinic Department
3. Pharmacy Unit
4.Clinical Microbiology (Dept Clinical Pathology and
Dept Microbiology)
 ANTIBIOTIC RESISTANCE PROGRAM SYSTEM
IN RSCM

Pharmacy and
Therapy Unit Clinical Microbiology

PPRA
(TEAM PPRA + Report
WORKING DIRECTOR
GROUP PPRA)

INFECTION CONTROL DEPT PHARMACOLOGY

COMMITTEE CLINIC
 PPRA
(Antimicrobial stewardship program)
• Antimicrobial stewardship
– Coordinated actions designed to promote and increase the
appropriate use of antimicrobials’
– Important strategy for the conservation of the effectiveness of
antibiotics.
• 2011: The compulsory criteria for hospital accreditation.
• 2014: Surgical antimicrobial prophylaxis prescribing is part of the
national Antimicrobial Stewardship Clinical Care Standard.
• Monitoring antimicrobial use and resistance is a requirement of
the National Safety and Quality Health Service Standards.
American Journal of Health-System Pharmacy ; 2013 ; 70 : 195 -283
 Core Elements of Hospital Antibiotic
Stewardship Programs
• Leadership Commitment: Dedicating necessary human, financial and
information technology resources.
• Accountability: Appointing a single leader responsible for program
outcomes. Experience with successful programs show that a
physician leader is effective.
• Drug Expertise: Appointing a single pharmacist leader responsible
for working to improve antibiotic use.
• Action: Implementing at least one recommended action, such as
systemic evaluation of ongoing treatment need after a set period of
initial treatment (i.e. “antibiotic time out” after 48 hours).
• Tracking: Monitoring antibiotic prescribing and resistance patterns.
• Reporting: Regular reporting information on antibiotic use and
resistance to doctors, nurses and relevant staff.
• Education: Educating clinicians about resistance and optimal
prescribing.
CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human
Services, CDC; 2014.
Available at http://www.cdc.gov/getsmart/healthcare/ implementation/core-elements.html.
 The Indonesian NAP AMR five
strategic objectives
1. Improve awareness and
understanding of AMR through
effective
communication, education and
training
2. Strengthen knowledge and
evidence base through
surveillance and research
3. Reduce incidence of infection
with sanitation, hygiene and
infection prevention
4. Optimise use of antimicrobial
medicines in human and animal
health
0
5. Develop economic case for
sustainable investment and
increase investment in new
medicines, diagnostic
tools, vaccines and other
interventions
PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 8 TAHUN 2015:
TENTANG PROGRAM PENGENDALIAN RESISTENSI ANTIMIKROBA DI RUMAH SAKIT
 Keterkaitan Program PPI dengan PPRA
Rumah sakit mempunyai program PPI dan kesehatan Kerja yang menyeluruh untuk
mengurangi risiko tertular infeksi yang berkaitan dengan pelayanan kesehatan pada
pasien, staf klinis, dan nonklinis, seperti:
a. Kebersihan tangan
b. Surveilans risiko infeksi
c. Investigasi KLB

d.Pengendalian resistensi antimikroba

e. Infection control risk assessment
f. Menentukan key performance indicator
g. Dan lain lain
PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 27 TAHUN 2017 :
TENTANG PEDOMAN PENCEGAHAN DAN PENGENDALIAN INFEKSI DI FASILITAS PELAYANAN KESEHATAN
RESISTANCE ANTIMICROBIAL PROGRAM
IN RSCM
1. Policy, implementation, dissemination and evaluation program
2. Program and plan of action
3. Routine report
4. Antibiotic policy
5. Link with PPRA Dept team
6. Consultation
PPRA TEAM

• Pediatrician
• Clinical Pharmacologist
• Pharmacist
• Microbiologist
• Clinical pathologist
• Surgeon
• ObGyn
• ID specialist
– Pediatricis
– Internal medicine
 ANTIBIOTIK POLICY SYSTEM
IN RSCM

Dept/UPT/Inst
Medical committee
Cq Pharmacy dan
Therapy

Team PPRA
Draft
Dept/Inst/UPT

AB BOOK
Team PPRA DIRECTOR
Clinical Microbiology GUIDANCE
ANTIBIOTIC MANUAL IN
RSCM
PROGRAM PENGENDALIAN RESISTENSI ANTIMIKROBA
(PPRA )
RSCM - DEPARTEMEN
ANTIBIOTIC STEWARDSHIP RSCM
Lini 1 Lini 2 Lini 3
Gentamisin Sefalosporin gen III Teicoplanin
Penisilin Fluorokuinolon Linezolid
Sefalosporin gen.I,II gen III-
III-IV Vancomisin
Kloramfenikol Fosfomisin Sefepime
Asam fusidat Cefoperazon--Sulbact
Cefoperazon Sefpirome
Lincosamid Carbapenem
Makrolida Tygecycline
Nitroimidazol Seftasidime
Fluorokuinolon Pip
Pip--Tazo
gen.I,II Aztreonam
Tetrasiklin
Amikasin
TMP--SMX
TMP
 PPRA team in RSCM
since2009
Quantitative

Antibiotic
evaluation

Qualitative
(Gyssens)

ANTIBIOTIC
EVALUATION
 AUDIT QUALITATIVE
Gyssens category
• I. Appropriate
• II. Inappropriate
a. dosage
b. interval
c. prescription
• III. Inappropriate
a. too long
b. too short
• IV. Inappropriate
a. there are antibiotics more effective
b. there are antibiotics less toxic / sfaer
c. there are antibiotics cheaper
d. there are antibiotics more specific (narrow spectrum)
• V. No indication
• VI. Medical record not complete
MONITORING AND EVALUATION:
CLINICAL ROUND
(Every Friday: 9-10 am)
 Aktivitas PPRA di RSCM
Global Antimicrobial Resistance Awareness Day RONDE PPRA DEPARTEMEN DI RSCM
Departemen IKA FKUI-RSCM SETIAP JUMAT

Penyakit
Meningitis bakterialis
Sepsis tanpa imunokompromais
PEDOMAN ANTIBIOTIK EMPIRIS PEDIATRIK
Antibiotik
Penyakit Antibiotik
Seftriakson 100mg/kgBB/hari per 12 jam 14 hari IV
CAP (Rawat Inap) Tanpa Komorbid Ampisilin 100mg/kg/hari per 6 jam IV + Kloramfenikol
Sefotaksim 25 mg/kg/dosis per 6-8 jam 7 hari IV 75 mg/kg/hari per 6 jam IV 5-7 hari

Sepsis Neonatorum Lini 1 (Early Amoksisillin-Klavulanat 50 mg/kg/dosis per 12 jam 7 hari IV +

Onset) Gentamisin 4-5 mg/kg/dosis IV Commjunity Acquired Pneumoniae CAP Amiksisilin 30-75 mg/kg/hari per 8 jam 5 hari PO atau
(Rawat Jalan) IV
Sepsis Neonatorum Lini 2 (Late Piperasilin Tazobaktam 50 mg/kg/dosis + Amikasin 7,5
Onset) mg/kg/dosis IV Eritromisin 40-60 mg/kg/hari per 6 jam 7 hari PO

GENTAMISIN
Hospital Acquired Penumoniae (HAP) Seflazidim 45-75 mg/kg/hari per 8 jam untuk 7 hari IV
BB (gram) Umur (hari) Interval (jam)

< 1200 ≤7 48
8-30 36 Demam Tifoid tanpa komplikasi Kloramfenikol 100mg/kgBB/hari per 6 jam 10-14 hari
> 30 24 PO atau IV

≥ 1200 ≤7 36 Demam tifoid dengan komplikasi Seftriakson 80 mg/kg/hari per 24 jam 5 hari IV
>7 24

PIPERASILIN-TAZOBAKTAM Disentri Sefiksim 8 mg/kg/hari per 12-24 jam 5 hari PO

Post Menstrual Agw (minggu) Postnatal (hari) Interval (jam)
Febril Neutropeni dalam Kemoterapi:
≤ 29 0-28 12
>28 8
Risiko Rendah Amoksisiklin-Klavilanat 50 mg/kg/hari per 8 jam 5
30-36 0-14 12
hari IV
>14 8

37-44 0-7 12 Risiko Tinggi Seftazidim 100 mg/kg/hari per 12 jam 5 hari IM atau
>7 8 IV

≥ 45 Semua 8 Sefepim 25 mg/kg/dosis per 12 jam 7 hari IV

AMIKASIN

Usia Gestasi (minggu) Interval Dosis (jam) ISK Sefotaksim IV

Pielonefritis akut pada anak Neonatus
<28 36 Usia ≤ 7 hari, ≤ 1200-2000 g: 100 mg/kg/hari per 12
28-29 24
jam
Usia > 7 hari, ≥ 2000 g: 150-200 mg/kg/hari per 6-8
30-35 18 jam
≥ 36 12
Anak
100mg/kg/hari per 8 jam
≥ 37, usia > 7 hari 8
Gentamisin 7 mg/kg per 24 jam IV
ANTIBIOTIC USAGE BASED ON GYSSENS CATHEGORY
DEPT CHILD HEALTH, RSCM, 2010
 GYSSEN CATEGORY IN 4 DEPARTMENT
RSCM 2016
90

79
80
72
70

60

50 48

40
33
29 29 30
30 28

20 16
14
11 11
9
10 6
43 4 3
2 2 1 2 122 1012 0011 0001 2
00 1 000 1 0 0011 0 0
0
VI V IV A IV B IV C IV D III A III B II A II B II C I 0

IPD IKA Bedah Obsgyn

 Defined Daily Dose (DDD): Dosis rharian
untuk indikasi tertentu pada orang dewasa
Audit
Eg:
Quantitative Tetrasiklin : 1 DDD = 1000 mg
Ampicillin : 1 DDD = 2000 mg
Amoxycillin :1 DDD = 1000 mg
Ceftriaxon : 1 DDD = 2000 mg

Penggunaan di rumah sakit :

DDD/100 patient-days (bed-days)
Penggunaan di komunitas :
DDD/1000 person-days (inhabitant-days)
 DDD RSCM 2012-2014
20.00
18.00
16.00
14.00
12.00
10.00
8.00
6.00
4.00 DDD per 100 hari rawat (2012)
2.00 DDD per 100 hari rawat (2013)
0.00 DDD per 100 hari rawat (2014)
MEROPENEM

SEFIKSIM
LEVOFLOKSASIN

SIPROFLOKSASIN
AMOKSISILIN KLAVULANAT

SEFOTAKSIM
METRONIDAZOL
AZITROMISIN

SEFTRIAKSON
AMPISILIN SULBAKTAM

1 2 3 4 5 6 7 8 9 10
 CONCLUSION
• Antimicrobial resistance is an integrated
program with prevention control infection
• Routine surveillance is the key to read the
signal
• Management support and coordination is a
key role
• All health-care workers responsibility
THANK YOU