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KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

Mariyatul Qibtiyah,S.Si,Apt,SpFRS

• Sekretaris KPRA KEMENKES R.I


• Sekretaris KPRA RSUD Dr.Soetomo Surabaya
• Koordinator Mutu & Diklit IFRS RSUD Dr.Soetomo
• Pengurus Pusat HISFARSI
• Sekretaris HISFARSI Jawa Timur
• Member of ISC-ASP (International Society of Chemotherapy
Antimicrobial Stewardship Program)

081 55039300 m_qibtiyah@yahoo.com m_qibti

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KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

RENCANA AKSI NASIONAL


PENGENDALIAN RESISTENSI ANTIMIKROBA:
Hasil Capaian dan Target ke Depan
(NATIONAL ACTION PLAN on AMR)

Mariyatul Qibtiyah, S.Si, Apt, SpFRS

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA (KPRA)


KEMENTERIAN KESEHATAN R.I
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ERA PRE-ANTIBIOTIC BEHAVIOUR AMR

ANTIBIOTIC ERA

misuse, HAIs, morbidity


overuse, mortality,
disability, ALOS,
underuse cost
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KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

Pengembangan antibiotik baru rata-rata


membutuhkan 10-15 tahun

Resistensi terjadi rata-rata 2 tahun


setelah antibiotik digunakan
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Antibiotic
KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA
use profile
Admit
Discharge
Category Evaluator range
(Gyssens) Sby (%) Smg (%)
Hospital as
resources AMR No indication
spreading 45 - 76 56 - 76
(treatment)
No indication
13 - 55 43 - 76
(prophylaxis)
Surabaya Semarang
Percentage
100 of resistant E. coli
90
80
to Fluoroquinlone between Hospital
E.Coli & 70 and Primary Health Care
Klebsiella 60
50 E.Coli
ESBL 40 K.Pneumoniae
30
20
10
0
cefot ceftr ceftaz

Admit Discharge PHC


AMRIN STUDY, 2000-2005 Kuntaman et al , EID, vol 11. no. 9/2005

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KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

GLOBAL RESISTANCE:
KLEBSIELLA PNEUMONIAE (ESBL+)

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DDD consumption of antibiotics


Surgical depart 2016
100

Prevalensi E.coli & Klebsiella pneumonia (ESBL+) 80

meningkat sejak 2000-2016 60

40

20

0
RS A RS B RS C RS D RS E RS F RS G RS H RS I RS J RS K RS L RS M RS N RS O

CEFTRIAXONE METRONIDAZOLE CIPROFLOXACIN

100
90
80
70
60
50
40
30
20
10
0
0 I II IIIA IV V VI

*data surveilans kajian AMR-AMU KPRA Kemenkes, 2016 RS A RS B RS C RS D RS E RS F

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KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA


Pertanian/
Peternakan
/perikanan
Growth Cegah Regula
promoto infeksi si
r

Food Kurikul
Knowled Residu AB Insent um
ge if
(+)
Proble Training
ms OTC/Apat
R/ AB AMR R
AB/ Knowle
/
Semina
Map ek self
medikasi RS DR
dge r
Worksh
AMR op

Regulasi SDM
ASP
Lab. Regul
SpM mikro asi
K
PNPK
PPK TOP
KM/K MGT
FT (-)

IDI/ PDSP/ IAI-


HISFARSI
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Structure of National
Antimicrobial Resistance Control Committee (ARCC) Ministry of Health
HK.02.02/MENKES/273/2014
sign on August 18, 2014
MINISTRY OF
HEALTH
PATRON

SECRETARY GENERAL
ADVISORY

STEERING
COMMITTEE
DIRECTOR GENERAL
OF HEALTH SERVICE

CHIEF

SECRETARY

MEMBERS

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Strategic Plan of AMR Control in Indonesia 2015-2019

Increasing Public Health quality through


OUTCOME AMR Control Program
(Diagnostic, Antibiotik usage, Infection management, AMR Spreading, Decreasing AMR
Incidence )
Realization of Community Care toward AMR Global Problem and
Update of AMR Collaboration between
To Develop AMR Control Implementation in Health Facilities control teaching material in Ministry of health, ministry
( % number of Health Facility included) ( (% understanding of AMR, % antibiotic consumption,% decreasing Health education of Agriculture and
OUTPUT

antibiotic OTC)) (Medical Doctor, vetenerary, ministry of


Pharmacetical, Nurse, education
Midwife)
Avaibility of AMR control Program funds
Implementation of AMR surveillance

Realization of
Realization of Realization of
STRATEGIC IMPLEMENTATION

Realization of AMR Control Realization of Realization of


Realization of AMR Control in education system
AMR Control in collaboration antibiotic selling collaboration
AMR Control in Private of AMR Problem
Primary Health within control and between gov.
Hospital Practice and control in
Facilities profesional monitoring and NGO
community
PROCES

setting
organization

Collaboration
Collaboration
Collaboration Collaboration of ministry of
between
Realization of AMR Information system base on health among health of medical agriculture
Realization of AMR Information system base on institution that
facilities faculty / profession and
community setting concern in
university collegium vetenerery
antibiotic use

Existing system of AMR control in Health facilities and community


SUMBER DAYA
KESEHATAN

Avalaible competent health provider in for AMR conrtol


program: Gov. Regulation support
(Phycisian, Clinical Microbiologist, Clinical pharmacist,
Facilities support for AMR Control program :
(National Policy, National guideline,
Clinical Pharmacologist, ICN) (Diagnostic, IC, Pharmaceutical fascilities)
Clinical guideline)

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KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

The ARCC MoH ….

• to develop strategic action plan for


AMR control
• to create recommendation for
improving health service through ARCP
program in health facilities and
community
• to develop program, including:
• AMR awareness health sector and
community
• ASP in Health facility
• Surveillance of AMR and AMU in hospital
and community setting
• Monitoring, evaluation and reporting

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NAP on AMR Indonesia one-health approach


Submitted to WHO library in May 2017

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NAP.1 Awareness and Understanding

Penyusunan NAP on AMR – One Health

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NAP.1 Awareness and Understanding

PMK No.8
th 2015

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Sosialisasi Dinkes Provinsi NAP.1 Awareness and Understanding

SAMARINDA KENDARI PAPUA BARAT

Sosialisasi kepada masyarakat, kader, guru

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KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

Community Program
• Television promotion
• Community Seminar in 34 Provinces
trough GEMA CERMAT
• Leaflet, posters, comics, sticker
• Competition and awards
• Antibiotic Awareness Week
(November)

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KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

BAKTERI
RESISTEN

MISUSE
OVERUSE
UNDERUSE

Resistance is unresponsiveness
to antimicrobial agents in
standard doses
TRANSMISION
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NAP
KOMITE PENGENDALIAN 2. Surveillance
RESISTENSI & Research
ANTIMIKROBA

Global Antimicrobial Surveilance System


(GLASS)
• December 2014: global consultation was held in Stockholm 
Key advice: development of an early implementation manual of
GLASS (Global AMR Surveillance System)
• Representatives from 30 countries, international experts on
AMR and WHA staffs  commitment to participate in
GLASS
• May 2015: WHA adopted GAP on AMR. NAP should be in place
by May 2017. Key element of GAP: collection and sharing of data
according to the proposed surveillance standards to guide and
evaluate intervention
• March 2016: launched of GLASS by WHO

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NAP 2. Surveillance & Research

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NAP 2. Surveillance & Research

*data surveilans kajian AMR-AMU KPRA Kemenkes, 2016-2017 22

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100.0 NAP.1 Surveillance & Research
Antibiotics use based on prescribing indicator report 90.0
Out patient
from public health centers (Puskesmas) 80.0
70.0
49.07 47.80 60.0
45.08 42.68
39.76 38.68 50.0
40.0 32.3 34.3 30.3 30.7
30.0 27.0
21.3 20.8 23.0
18.8
20.0 15.0 14.8
9.2 10.2 8.3
10.0 3.8
0.0
RS A RS B RS C RS D RS E RS F RS G RS H RS I RS J RS K RS L RS M RS N RS O
% AB use on Acute Upper Respiratory Tract Infection Percentage of antibiotic consumption at 15 hospitals 2016
2011 2012 2013 2014 2015 2016
100
90 82.17
In patient 77.53 78.65
48.00 80
44.30 44.15 71.17
41.28 41.16 67.12
36.54 70 64.3361.75
60 53 55.5 58.17
50 41.18 44
40 35.75 35.82
29.35
30
20
% AB use onunspesified diarrhea 10
2011 2012 2013 2014 2015 2016 0
23M RS N
RS A RS B RS C RS D RS E RS F RS G RS H RS U RS I RS J RS K RS L RS

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

NAP 2. Surveillance & Research

Antibiotics Consumption of Inpatients at 15 Hospitals 2016 Qualitative Audit of Antibiotic Use at 6 Hospitals, 2016
(DDD/100 patient-days)
(Gyssens Flowchart Method)
100.00 96.31 100
90
90.00
78.08 80
80.00
70.58 70
70.00 67.64
60
60.00 52.52 50
48.12 50.19 48.03 50.34
50.00 40
40.06 30
40.00 35.14 37.18
34.21 31.87 32.79
20
30.00
10
20.00
0
10.00 0 I II IIIA IV V VI
0.00
RS A RS B RS C RS D RS E RS F RS G RS H RS I RS J RS K RS L RS M RS N RS O RS A RS B RS C RS D RS E RS F

*data surveilans kajian AMR-AMU KPRA Kemenkes, 2016-2017


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MASALAH AKIBAT AMR

• Kegagalan terapi.
• Kegagalan operasi canggih,
kompleks
• menimbulkan beban
morbiditas, mortalitas,
kecacatan
• COST

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NAP 3. Infection Prevention Control (IPC)

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NAP 4. Optimize the use of antimicrobial

PRUDENT USE OF ANTIBIOTIC


Prudent use of antibiotics has 3 components:
• rational use
• adherence to local guidelines and policies
• avoidance or reversal of upward demographic trends in antibiotic
resistance (Phillips, CID. 2001)

The prudent use of antimicrobials as usage of antimicrobials which


maximizes therapeutic effect and minimizes the development of
antimicrobial resistance (WHO, 2008)
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NAP 4. Optimize the use of antimicrobial

Goals ASP
1. Decrease antibiotic usage quantity
and increase of quality
2. Optimize clinical response and
outcome
3. Increase guideline compliance
4. Reduce resistance or MDRO such
as ESBL, MRSA, CRE, NDM-1
5. Reduce hospitalization cost
Ohl CA. Seminar Infect Control 2001;1:210-21.
Ohl CA, Luther VP. J. Hosp. Med. 2011;6:S4
Mariyatul Qibtiyah Dellit TH, et. al. Clin Infect Dis. 2007;44:159-177 28

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NAP 4. Optimize the use of antimicrobial

Improvement after ASP implementation

Fishman N. Am J Med 2006;119:S53.

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NAP 4. Optimize the use of antimicrobial

• Core members of a multidisciplinary


antimicrobial stewardship team:
• An infectious disease physician
• A clinical pharmacist with infectious diseases
training
• Clinical microbiologist
• Infection Control Officer
• IT specialist
• Very good to have: epidemiologist

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NAP 4. Optimize the use of antimicrobial

KEBIJAKAN PENGENDALIAN
ANTIBTIOTIK DI RUMAH SAKIT

Keputusan Direktur RSUD Dr.Soetomo


No: 188.4 / 237 / 301 / 2018
Tentang
Kebijakan Pengendalian Penggunaan Antibiotik
RSUD Dr.Soetomo

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CORE PLAN DI RUMAH SAKIT

• PREVALENSI HAI ? • SARANA LAB MIKRO


• SDM
• GL HAI
• SURVEILLANCE

HAI AMR

• PNPK/PPG/CP

• DALIN
TRANS
MISI AB • ASP
• REVIEW
• CUCI TANGAN
• HE AB
• ISOLASI RESTRICTION

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HARAPAN: Peresepan dan penggunaan


antibiotik semakin BIJAK
HARAPAN Healthcare-associated
infections (HAIs) semakin turun (25%)
70

HARAPAN Turunnya prevalensi bakteri 60 60

penghasil ESBL nasional 50

presentage
40 40 40
35
ESBL
PPRA bukan revenue centre, tetapi 30 28
25
20
cost saving 10 9
0
2000 2005 2010 2013 2016 2018 2020

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Terima Kasih
Thank You

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