Prof. Kuntaman - Pelayanan Mikrobiologi Klinik - PPRA KARS CP

KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA
Pelayanan Mikrobiologi Klinik
Kuntaman
Dep Mikrobiologi FKUA/RSUD Dr Soetomo SBY
KPRA RSUD Dr Soetomo Sby / KEMENKES R.I.
1
Tiga area Pelayanan Spesialis Mikrobiologi Klinik

1. Pemeriksaan laboratorium
2. Konsultasi interpretasi pemeriksaan mikrobiologi
3. Penanganan penyakit infeksi
Finch et al, 2005
Meliputi sekitar 200 Kompetensi; ditempuh dalam 7 Semester

2
The Laboratory Services on Clin Micro
q Staining
q Culture
q Immuno-serology of Infection
q Molecular Diagnosis
- for Non Cultivable Microbes
- for Fast Diagnosis
- for Fast Susceptibility test
ü Mikroskopi
Diag Cepat ü Aglutinasi
ü Kultur cepat 3
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
–Rupiah: ????
Diagn. Micro.Infect.Dis, 91;14:157-66 4
Peran Mikrobiologi Klinik

Di Lab Mikro Klinik:
• Penanggungjawab
Ruang Perawatan:
• Konsultan penyakit infeksi
• Ada Infeksi ? Penyebab ?
• Pilihan AB
• Tim PPI: Pencegahan dan penanggulangan
infeksi nosokomial; Penanganan wabah
Tujuan Pemeriksaan Mikrobiologi
• Identifikasi MO (Bakteri/jamur) penyebab

(di spesimen)
• Penentuan Kepekaan thd AB
• Steril: infeksi non-bakteriil/non-jamur?
Atau infeksi di tempat lain?
• Pneumonia: Blood Culture Neg: ??
• Menentukan pathogen penyebab INFEKSI
Pemeriksaan Mikrobiologi
• Tidak harus mahal
• Bisa mulai cara sederhana & murah
• Bisa kerjasama dgn Lab Swasta terdekat
• Atau melatih Tenaga D3 Lab
• Penting: bisa memberi sokusi bagi dokter Klinik untuk
memilih antibiotika terapi
Case-1: Yan MK di Ward: What Res & Infection
Clin-Lab Clin-Lab
T: 38.5 C T: 37.5 C
Leu: 17.000 Leu: 12.000
K.pneu-ESBL K.pneu-ESBL
AK AK
Interaction: AB ßàM.O. ßà Host

Non Prudent AB: à Resistance:
Clin-Lab Clin-Lab
Selection Pressure
T: 38.5 C à T: 37.5 C
Induce ResLeu: 17.000 Leu: 12.000
Sen à ResK.pneu-ESBL K.pneu-ESBL
How it develop
AK to res AK
Interaction: AB ßàM.O. ßà Host

More AB à More Resistance:

Ab: ??
K pneu
ESBL
E coli
Carb Res
Pse aeru
Pan-Res
Aciba
Ab-gram
Use Reserve AB à Facing for MDRO & Pan-DR
MEM
AK MDRO
LEV
HW Spread
Diagnosis
Sepsis (Systemic infection)

Model (Mandell, 2004)
SIRS Systemic Inflammatory

Response Syndrome
Source of infection
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Sepsis (Mandell, 2004)
1. Temp >= 38 C (Rect); 37.8 C (Ax)
SIRS < 36 C
2. Pulse > 90/mnt
>=2 3. Resp > 20/mnt or P O2 < 32 mmHg/l
4. Leucocyte > 12 million/ml
Crp: ?? < 4 million/ml
PCT: ? > 10% Cell Immature
Source of infection Find out Culture
• Bacteremia
• Lung (pneumonia)
• Bladder (UTI)
• Intestine (Gastroenteritis) etc 13
Biasanya: ?
1) HAP/VAP
CAP Ab-1 Ab-1
2) SSI
HAP Ab-2 Ab-1
3) UTI
4) BSI VAP Ab-3 Ab-1
What bacteria are common: ??

First time to see the patient:
• Infection: ??
• What m.o. is there:??
• CAP: K pneu; Str pneu à AMC, Lev

• HAP: K pneu, Aciba; Pse aer à Local data:?
Terapi Empirik:
1. AB yang paling kuat: ??? ß Antibiogram:?
2. Dosis setinggi mungkin: ??
ü Siapa yang menentukan AB terkuat untuk infeksi
tertentu: ??
ü Dan Bgmn memilih: ??
3. Hanya antibiogram à belum cukup: ??
Antibiogram
• Epidemiological data of AMR:

• Pattern of bacterial isolates
(Species/Genus)
• Certain Specimen, Disease
• Pattern of Susceptibility
• For empiric therapy
17
How to develop Antibiogram as

a Pivotal Role in Management
of Inf Dis
Landborg et al, 2002

Larsson et al, 2000
18
AB-gram:
- a collection of data & table summarizing % of individual
bacterial pathogens susceptible to different antimicrobial
agents
- from isolated (as from a patient) and subjected to

laboratory testing.
- Local hospitals creating antibiograms, or tables that chart
the resistance
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How to develop AB-gram
1. Collecting of all the data, and print-

out : ?? or
2. Conducting surveillance directed to
the problem: ??
3. Selected pathogens based on all the
data: ??
4. Then make tabulation: design & style
?? easier to read and interpretation
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Problems in Micro Services in INA

1. Not all hospital commit to use one method for Micro culture for all
patients: automatic vs conventional
2. All data were collected, of both pathogens vs contaminants
3. More pathogens come from one patient
Make BIAS
More difficult to use as Clin Micro
Finch etServices
al, 2005
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What Next
1. Do the best way as we have

2. Plan the better steps
3. Think global standard, for locally; then improve the
local data step-by-step, with increasing the quality of
Clin Micro services,
4. otherwise ????????
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AB-gram Structure
1. Specify: Ward & Time

2. Base on one dis/specimen
3. Short the pathogens or frequency or both
4. Each pathogen à specify the AB
5. Quantity of pathogens: ?
6. Choose AB base on CLSI – guide the clinically
use
• S aureus (expl):
ü P FOX/OX, ERY DA SXT
ü TET/TGC RIF VAN LNZ
ü add: LEV/CIP NIT
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Number too small: ?? Other Issues: ??
1. Years 1. Duplicate isolate: ??

2. species (grouping) 2. Data represents for
3. geographically diagnostic purposes
4. + data from published 3. Data is stratified à
AB-gram ü Infection site
5. Make any footnote as ü Adult vs pediatric
needed ü ICU vs non-ICU
4. etc
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HAP
Antibiogram ICU, Sputum, 2014, Dr Soetomo Hosp

Microbes Quant %
Ac baumannii/compl. 129 41%
Pseu aeruginosa 67 21%
80% GN
K. pneumoniae 56 18%
E coli 26
98%
Burkholderia cepacia 15
Stenotropo maltophilia 7
Enter cloacae 7
Enter aerogenes 5
Staphy aureus 6 2%
Total 318
Isolat Sputum RSUD DS Jan-April 2018

1289 isolat Sputum:
Aciba: 261 = 20%
K pneu: 244 = 19%
Ps aeru: 148 = 12%
51%
--- ---- ---- --- ---- ----------
Enterobacter spp: 79=6%
Staph spp: 61= 5%
Candida spp: 49 = 4%
HAIs
1) HAP/VAP
2) SSI
3) UTI
4) BSI

Bacterial agents in Wound

542 swab/wound:
E coli: 120 22%
Staph spp: 92 17%
Pse aeru: 65 12%
ESBL Strep spp : 46 9%
K pneu: 42 8%
Aciba: 42 8%
GNB:45% ESBL Entero spp: 14 3%
Others Others
HAIs
1) HAP/VAP
2) SSI
3) UTI
4) BSI

RSDS, 2018 ISK

Total: 977
E coli: 365 37%
K. pneu: 104 11%
Pse aeru: 77 8%
Aciba: 42 4%
Staph spp: 36 4%
Candida spp: 96 10%
Infectious Diseases Expert Resources

Infectious Diseases
Specialists
Healthcare Infection Control
Epidemiologists Professionals
Clinical Optimal
Pharmacists Patient Care
Clinical Clinical
Microbiologists Pharmacologists
Surgical Infection
Experts
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings, CDC
RINGKASAN
1. Pelayanan Mikrobiologi Klinik:

ü Dari Lab sampai dengan Ruang perawatan
ü Sebelum pemeriksaan Mikro sampai setelah
ada pemeriksaan mikro klinik
2. Diagnosis mikrobiologi:
• Mulai pengecatan sampai biakan
• Mulai cara sederhana sd cara cepat
32
RINGKASAN
3. Interpretasi klinik hasil Lab Mikro, bisa dilakukan lebih terarah
di tempat perawatan penderita
4. Hasil pemeriksaan mikrobiologi klinik bisa dipakai:
a. Dasar terapi empirik untuk masa akan datang
b. Dasar terapi definitif saat ini
c. Analisis penggunaan antibiotika saat lampau
dan kini
5. Peningkatan peran pelayanan mikrobiologi klinik akan bisa
menghemat obat, waktu dan uang. Juga menyelamatkan
lingkungan terhadap pengaruh antibiotika
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RINGKASAN
6. Infeksi sulit à Perlu Perawatan bersama

7. Prinsip pemilihan AB yg bijak: sensitif, efektif, murah,
generasi lebih lama, efek samping kecil
8. AB bijak à menuju
• Kendali mutu &
• Kendali biaya
9. Sering: SULIT menetapkan INFEKSI atau KOLONISASI
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Prof. Kuntaman - Pelayanan Mikrobiologi Klinik - PPRA KARS CP

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Prof. Kuntaman - Pelayanan Mikrobiologi Klinik - PPRA KARS CP

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KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA

Pelayanan Mikrobiologi Klinik

Tiga area Pelayanan Spesialis Mikrobiologi Klinik

Finch et al, 2005

Meliputi sekitar 200 Kompetensi; ditempuh dalam 7 Semester

Without direct consultation, recommendation

Peran Mikrobiologi Klinik

Tujuan Pemeriksaan Mikrobiologi

• Identifikasi MO (Bakteri/jamur) penyebab

Case-1: Yan MK di Ward: What Res & Infection

Interaction: AB ßàM.O. ßà Host

Non Prudent AB: à Resistance:

Interaction: AB ßàM.O. ßà Host

More AB à More Resistance:

Use Reserve AB à Facing for MDRO & Pan-DR

Sepsis (Systemic infection)

SIRS Systemic Inflammatory

4) BSI VAP Ab-3 Ab-1

What bacteria are common: ??

First time to see the patient:

• CAP: K pneu; Str pneu à AMC, Lev

• Epidemiological data of AMR:

• For empiric therapy

How to develop Antibiogram as

Landborg et al, 2002

- from isolated (as from a patient) and subjected to

How to develop AB-gram

1. Collecting of all the data, and print-

Problems in Micro Services in INA

1. Do the best way as we have

1. Specify: Ward & Time

Number too small: ?? Other Issues: ??

1. Years 1. Duplicate isolate: ??

Antibiogram ICU, Sputum, 2014, Dr Soetomo Hosp

Isolat Sputum RSUD DS Jan-April 2018

What bacteria are common: ??

Bacterial agents in Wound

What bacteria are common: ??

RSDS, 2018 ISK

Infectious Diseases Expert Resources

1. Pelayanan Mikrobiologi Klinik:

6. Infeksi sulit à Perlu Perawatan bersama

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