AMRIN

AntiMicrobial Resistance
Indonesia

Peterhans van den Broek

on behalf of the
AMRIN study group
 AMRIN

• Antimicrobial resistance
• Antibiotic usage
• Infection control
 Driving forces behind
antimicrobial resistance

Selection Exchange Spread

R
Selection
 R
Exchange
R
R

R
R
Conjugation Transduction
Spread
• Air
• Droplets
• Contact
• Water
• Food
• Blood
• Vectors
 Example
Staphylococcus aureus
 Example
Staphylococcus aureus

1941
 Example
Staphylococcus aureus

1941 1944
 Example
Staphylococcus aureus

1941 1944 1959

 Example
Staphylococcus aureus

1941 1944 1959 1961

 Example
Staphylococcus aureus

1959 1961 1991

 Example
Staphylococcus aureus

1959 1961 1991 1997

 Example
Staphylococcus aureus

1991 1997 2002

Prevention of resistance
=
Prevention of selection
and
Prevention of spread
 Prevention of selection
=
Prudent use of antibiotics
 Prudent use of antibiotics
• Use antibiotics on strict indication
• Use narrow spectrum antibiotics
• Use antibiotics not too long
• Focus antibiotic therapy according to
bacteriological results
Prevention of spread
=
Infection control
 Essential needs for
effective infection control
• Dedicated personnel
– infection control nurse
– epidemiologist
• Protocols
• Active infection prevention policy
– surveillance
– audit
– outbreak management

SENIC project
 AMRIN
1e phase questions
• What is the prevalence of antimicrobial
resistance?
• What is the quantity and quality of
antibiotic usage?
• What is the quantity and quality of
infection control?
 Antimicrobial resistance
• Staphylococcus aureus
– Tetracycline resistance (24%)
– Oxacillin resistance (9%, no MecA gene)
• Escherichia coli
– Resistance to ampicillin, chloramphenicol,
cefotaxim, ciprofloxacin
– especially high in patients discharged from
hospital
 Antimicobial resistance
Escherichia coli, % resistance
in hospitalized patients

Surabaya LUMC
Ampicillin 52 50
Cefotaxim 9 -
Cefuroxim - 6
Ceftazidim - 1
Gentamicin 15 15
Ciprofloxacin 18 7
Cotrimoxazole 52 27
 Antibiotic usage
• Antibiotic usage high
 Antibiotic usage
Antibiotic DDD/1000 person days DDD/100 bed days

Tetracyclines 1.4 0.04

Amphenicols 0.5 0.9

Penicillins 13.4 29.4

Cephalosporins - 9.7

Cotrimoxazole 1.2 0.8

Macrolides 0.1 0.3

Lincosamides - 0.8

Aminoglycosides 0.3 3.3

Quinolones 0.2 0.8

Metronidazole 0.1 6.4

Rifampicin 0.8 0.2

Total 18 53
Antibiotic usage in Europe
Antibiotic usage in Europe

S
U
R
A
B
A
Y
A
 Antibiotic usage
• Antibiotic usage high
• Frequently no indication for antibiotic
therapy
– Internal reviewer 20-36%
– External reviewer 10-76%
 Infection control
• Number of nosocomial infections not less
than elsewhere in the world; problems
with using definitions
• Prerequisites for optimal infection
control can be improved
– dedicated personnel (i.e. fulltime)
– protocols
– active infection prevention policy
Prevalence nosocomial infections
Prevalence
(%)
Phlebitis 2.8
Urinary tract infection 1.1
Surgical wound infection 1.3
Clinical sepsis 0.8
Total 6.0
Possible 0.4
Prevalence nosocomial infections
Prevalence
(%)
Phlebitis 2.8
Urinary tract infection 1.1
Surgical wound infection 1.3 4.7
Clinical sepsis 0.8
Total 6.0
Possible 0.4
 Quality improvement:
a never ending process
AMRIN 2e phase

Guidelines
Evaluation of
Protocols
actual situation
Standards

Improvement Identification of
activities quality problems
AMRIN study
2e phase
Intervention studies
 Why interventions?
AMRIN 2e phase

Guidelines
Evaluation of
Protocols
actual situation
Standards

Improvement Identification of
activities quality problems
Quality improvement is a never ending
process!
Nobody ever can say: I am at the top!
Guidelines
Evaluation of
Protocols
actual situation
Standards

Improvement Identification of
activities quality problems
 Intervention
Problem

Proposal(s) for change(s)

Proposal(s) for intervention(s)

Barriers against change

Final planning of intervention

implementation

evaluation
 Intervention
Problem

Proposal(s) for change(s)

Proposal(s) for intervention(s)

Barriers against change

Final planning of intervention

implementation

evaluation
 Problems
1. Antibiotics often prescribed without
indication
2. Surveillance of nosocomial infections
sub optimal
3. Basics of hospital hygiene sub optimal
 Intervention
Problem

Proposal(s) for change(s)

Proposal(s) for intervention(s)

Barriers against change

Final planning of intervention

implementation

evaluation
 Proposals for change
1. Decrease number of not-indicated
prescriptions

By doing so:
– Decrease amount of antibiotics used
– Decrease antimicrobial resistance
 Proposals for change
2. Improve surveillance of nosocomial
infections.

By doing so:
– get more reliable and informative data
– decrease number of nosocomial infections
by directed actions
– decrease antimicrobial resistance
 Proposals for change
3. Improve basic standards of hospital
hygiene.

By doing so
– decrease spread of resistant bacteria
– decrease antimicrobial resistance
– decrease number of nosocomial infections
 Intervention
Problem

Proposal(s) for change(s)

Proposal(s) for intervention(s)

Barriers against change

Final planning of intervention

implementation

evaluation
 Proposals for interventions
1. To decrease number of not-indicated
prescription:

– introduce protocol for surgical prophylaxis

(surgical departments)
– introduce protocol for management of
patients with fever
(internal medicine departments)
 Proposals for interventions
2. To optimise surveillance of nosocomial
infections:

– Introduce standard procedure for

surveillance of surgical wound infections
(in relationship with prophylaxis protocol)
 Proposals for interventions
3. To optimise basic standards of hospital
hygiene:

– introduce protocols for standard

precautions on clinical wards
 Intervention
Problem

Proposal(s) for change(s)

Proposal(s) for intervention(s)

Barriers against change

Final planning of intervention

implementation

evaluation
 Design of interventions

• Three periods
– before measurements
– protocol development
– after measurements
• Use of controls
• Protocols based on consensus
 AMRIN
final goal
Validated methods to
– monitor antimicrobial resistance
– monitor antibiotic usage
– monitor nosocomial infections
– assess quality of antibiotic prescription
– assess quality of infection control
– improve quality of antibiotic prescription
– improve quality of infection control
A wanted side effect of AMRIN

The infectious diseases

service line
 Infectious diseases service line

Infectious
diseases
specialist Infection
control
nurse
Antibiotic
committee Infection control
committee

Clinical Clinical
microbiologist pharmacist
 Infectious diseases service line

Infectious Infection
diseases control
specialist nurse
Antibiotic
committee Infection control
committee

Clinical Clinical
microbiologist pharmacist
 Infectious diseases service line
* Treating physician
* Consultations:
- clinical assessment
Infectious - diagnostic tests Infection
diseases
- antimicrobial therapycontrol
specialist nurse
Antibiotic - antimicrobial prophylaxis
committee - prevention Infection control
committee

Clinical Clinical
microbiologist pharmacist
 Infectious diseases service line

Infectious Infection
diseases control
specialist nurse
Antibiotic
committee Infection control
committee

Clinical Clinical
microbiologist pharmacist
 Infectious diseases service line

Infectious Infection
diseases control
specialist nurse
Antibiotic
committee Infection control
committee

Clinical
microbiologist
Clinical
pharmacist
 Infectious diseases service line

Infectious Infection
diseases control
specialist nurse
Antibiotic * Responsible for micro-
committee biological laboratory
Infection control
* Consultations committee
- microbiological tests
Clinical - antimicrobial resistance
microbiologist
- antimicrobial therapy
- antimicrobial prophylaxis
Clinical
- prevention pharmacist
 Infectious diseases service line

Infectious Infection
diseases control
specialist nurse
Antibiotic
committee Infection control
committee

Clinical
microbiologist
Clinical
pharmacist
 Infectious diseases service line

Infectious Infection
diseases control
specialist nurse
Antibiotic
committee Infection control
committee

Clinical
Clinical
pharmacist
microbiologist
 Infectious diseases service line

Infectious Infection
diseases control
specialist nurse
Antibiotic
committee Infection control
committee

Clinical
Clinical
pharmacist
microbiologist - drug dosing
- drug monitoring
 Infectious diseases service line

Infectious Infection
diseases control
specialist nurse
Antibiotic
committee Infection control
committee

Clinical
Clinical
pharmacist
microbiologist
 Infectious diseases service line

Infectious Infection
diseases control
specialist nurse
Antibiotic
committee Infection control
committee

Clinical
Clinical
pharmacist
microbiologist
 Infectious diseases service line

Prevention
Infectious Infection
diseases control
specialist nurse
Antibiotic
committee Infection control
committee

Clinical
Clinical
pharmacist
microbiologist
 Infectious diseases service line
Quality system
- guidelines
- monitoring antibiotic use
Infectious Infection
- education diseases control
specialist nurse
Antibiotic
committee Infection control
committee

Clinical
Clinical
pharmacist
microbiologist
 Infectious diseases service line
Quality system
Quality system
- guidelines
- guidelines
- surveillance nosocomial
- surveillance antibiotic use
Infectious Infectioninfections
- education diseases control- outbreak management
specialist nurse- education
Antibiotic
committee Infection control
committee

Clinical
Clinical
pharmacist
microbiologist
 Infectious diseases service line

Infectious Infection
diseases control
specialist nurse
Antibiotic
committee Infection control
committee

Clinical
Clinical
pharmacist
microbiologist
 Infectious diseases service line

Infectious Infection
diseases control
specialist nurse
Antibiotic
committee Infection control
committee

Clinical
Clinical
pharmacist
microbiologist
 Infectious diseases service line
network
Infectious Infection
diseases control
specialist nurse
Antibiotic
committee Infection control
committee

Clinical
Clinical
pharmacist
microbiologist
 AMRIN and the Infectious
diseases service network in
dr Soetomo hospital
• Capacity building
– training
– research
• Validated methods
Terima kasih!