FARMAKOTERAPI

PENYAKIT
INFEKSI
Dr. Widya7, MClin Pharm, Apt
Farmasis Klinik RSAL dr. Ramelan
Dosen FF Ubaya
 PRINSIP TERAPI INFEKSI
•  Pas7kan infeksi
•  Pemilihan an7bio7ka harus tepat
•  Perha7kan underlying disease
•  Sesuaikan dosis pada Gagal ginjal, gangguan ha7
•  Monitoring outcome
•  Awasi interaksi
•  Awasi adrac
•  Tinjau kembali terapi yang gagal
PASTIKAN TANDA INFEKSI
 Tanda Klinis Infeksi
Lokal Sistemik
•  Diare, mual, muntah, distensi •  Hipotermia atau
abdomen hipertermia
•  Disuria, frekuensi urinasi
meningkat (ISK) •  Malaise
•  Sakit kepala, kaku leher, •  Takikardia
fotopobia, kejang (Meningi7s) •  Takipnea
•  Nyeri, inflamasi di tempat infeksi
lokal (eritema, pembengkakan, •  Hipotensi
luka, lesi kulit, abses) •  Hipoksemia, asidosis/
•  Pus, cairan vagina/uretral alkalosis
•  Sputum dan batuk (Pneumonia) •  Perubahan status mental
•  Menggigil
•  Lemah
 Tanda Laboratoris Infeksi
•  Elevasi ESR (penyakit kronis), CRP (inflamasi),
or Procalcitonin (sepsis)
•  Elevasi atau depresiasi WBC/Leukosit
•  Elevasi lactate
•  Shi$ to the le$
•  Tes an7gen atau 7ter an7bodi posi7f
•  Pewarnaan Gram dan atau kultur dari tempat
infeksi posi7f
 Tanda Radiologis Infeksi
•  Rontgen tulang atau MRI dengan elevasi
periosteal atau destruksi tulang pada pasien
dengan osteomyeli7s
•  Rontgen thorax atau CT dengan konsolidasi,
infiltrat, efusi, atau nodul pada infeksi tulang.
•  USG abdomen atau CT dengan buk7 perforasi
atau abses
•  Echocardiografi dengan vegetasi menunjukkan
endokardi7s
•  CT/MRI Kepala dengan lesi pada abses otak.
 2. Apakah merupakan
penyakit infeksi bakteri ?

7
PEMILIHAN ANTIBIOTIKA
Campaign to Prevent An=microbial Resistance in Healthcare SeGngs

Selec7on for an7microbial-resistant

Strains

Resistant Strains
Rare

An=microbial x x
x x
Exposure

Resistant Strains
Dominant
 8. Dasar pemilihan an=bio=k

a.  An=bio=k empirik

•  Sementara
•  Ditentukan berdasarkan petamedan/
pengalaman retrospek7f

b.  An=bio=k defini=f

•  Berdasarkan pemeriksaan mikrobiologi

10
 FAKTOR
INFEKSI

FAKTOR FAKTOR
ANTIBIOTIKA PASIEN

PEMILIHAN
ANTIBIOTIKA
 FAKTOR PASIEN

•  Penyakit Penyerta
•  Renal atau hepa7c func7on
•  Age
•  Gene=c Varia=on
•  Alergi
•  Kehamilan
•  History of Recent An=microbial Use.
 FAKTOR PATOGEN
q  Bakteri : ?
q Jenis infeksi: Nosokomial / community
q Bakteri Nosokomial : Enterococcus sp,
Staphylococcus Aureus, Klebsiella sp,
Acinetobacter, Pseudomona sp., E. Coli (ESKAPE)
q Pola Susep7bilitas
•  Bervariasi antar bangsal, antar RS
•  Berubah sangat cepat bila ada clone yang resisten
dan menyebar
q Using MIC data

 Interpreta=on of An=microbial Suscep=bility Tes=ng
Results

•  the lowest concentra7on of an an7bio7c that inhibits

visible growth of a microorganism, and are interpreted
by the laboratory as “suscep7ble,” “resistant,” or
“intermediate,” according to Clinical and Laboratory
Standards Ins7tute criteria.
•  MICs of different agents for a par7cular organism are
not directly comparable. For example, MICs of 1
(suscep7ble) for ciprofloxacin and 2 (suscep7ble) for
cebriaxone against Escherichia coli do not imply that
ciprofloxacin is twice as ac7ve as cebriaxone.
 INTERPRETASI HASIL KULTUR
•  Diameter zona hambat bukan cerminan
sensi7vitas
•  Tidak ada pertumbuhan kuman
mengimplikasikan →betul-betul steril atau
bakteri anaerob atau jamur
•  Kultur bakteri anaerob, jamur: perlu media
khusus dg lama kultur 7-14 hari
Coloniza7on vs Contamina7on vs Infec7on
•  Coloniza7on: the presence of mo without host
inflammatory response
•  Contamina7on: the presence of mo typically
acquired during acquisi7on or processing of
host specimen without evidence of host
inflammatory response
•  Infec7on: the presence of one or more mo
with host inflammatory response.
 Coloniza7on/Contamina7on vs
Infec7on
Coloniza=on/Contamina=on Infec=on
• Normal WBC •  WBC ↑ or ↓
•  WBC unchanged in indolent
or subacute infec7on
• Not typically associated with WBC •  WBC oben present
• Normothermia •  Hyperthermia or
hypothermia
• Usually not associated with •  More oben associated with
heavy growth of pathogen on a heavy growth of pathogen
Gram stain on a Gram stain
 Sterile Anatomical Sites
•  Def: Sites that are normally sterile i.e. CSF,
blood, lungs, UT, and billiary tract
•  If m.o. are cultured from those sites, they may
likely be pathogenic
•  Some7mes represent contamina7on or
coloniza7on. Clinical correla7on is esen7al for
interpreta7on,
 Non-Sterile Anatomical Sites
•  Def: Sites that are normally non-sterile
including sputum, pus, skin swabs, GI tract
and vagina.
•  It is expected that mo will grow in specimen
from non-sterile sites.
•  Consider whether the iden7fied mo correlate
to the clinical syndrome.
FAKTOR ANTIBIOTIKA
 FAKTOR ANTIBIOTIKA

•  Dosis, Rute, bentuk obat
•  Penetrasi ke tempat infeksi
•  Farmakokine7ka-Farmakodinamika
•  Kombinasi A.B
•  Switch Therapy
•  Lama terapi
•  Frekuensi
•  Harga
 Empiric vs Defini=ve An=microbial
Therapy
•  Microbiological results do not become available for 24
to 72 hours,
•  Ini7al therapy for infec7on is oben empiric and guided
by the clinical presenta7on
•  Inadequate therapy for infec7ons in cri7cally ill,
hospitalized pa7ents is associated with poor
outcomes,greater morbidity and mortality as well as
increased length of stay.
•  Common approach is to use broad-spectrum
an7microbial agents as ini7al empiric therapy
(some7mes with a combina7on of an7microbial
agents;
Table 56-1 Classifica=on of Infec=ous Organisms

1. Bacteria Gram-nega+ve
Aerobic Cocci
Gram-posi+ve None
Cocci Rods (bacilli)
Streptococci: pneumococcus, viridans Bacteroides (Bacteroides fragilis, Bacteroides
streptococci; group A streptococci melaninogenicus)
Enterococcus Fusobacterium
Staphylococci: Staphylococcus aureus, Prevotella
Staphylococcus epidermidis 2. Fungi
Rods (bacilli) Aspergillus, Candida, Coccidioides,
Corynebacterium Cryptococcus, Histoplasma, Mucor, Tinea,
Listeria Trichophyton
Gram-nega+ve 3. Viruses
Cocci Influenza, hepa77s A, B, C, D, E; human
Moraxella immunodeficiency virus; rubella; herpes;
Neisseria (Neisseria meningiAdes. Neisseria cytomegalovirus; respiratory syncy7al virus;
gonorrhoeae). Epstein-Barr virus, severe acute respiratory
Rods (bacilli) syndrome (SARS) virus
Enterobacteriaceae (Escherichia coli, 4. Chlamydiae
Klebsiella, Enterobacter, Citrobacter, Proteus, Chlamydia trachomaAs
SerraAa, Salmonella, Shigella, Morganella, Chlamydia psiKaci
Providencia) Chlamydia pneumoniae
Table 56-2 Site of Infec=on: Suspected
Organisms

Site/Type of InfecAon Suspected Organisms

1. Respiratory
Pharyngi7s Viral, group A streptococci
Bronchi7s, o77s Viral, Haemophilus influenzae, Streptococcus
pneumoniae, Moraxella catarrhalis
Acute sinusi7s Viral, Streptococcus pneumoniae,
Haemophilus influenzae, Moraxella catarrhalis
Chronic sinusi7s Anaerobes, Staphylococcus aureus (as well as
suspected organisms associated with acute
sinusi7s)
Epigloo7s Haemophilus influenzae
Pneumonia
Community-Acquired
Normal host Streptococcus pneumoniae, viral, mycoplasma
Aspira7on Normal aerobic and anaerobic mouth flora
Pediatrics Streptococcus pneumoniae, Haemophilus
influenzae
COAD Streptococcus pneumoniae, Haemophilus
influenzae, Legionella, Chlamydia,
Table 56-3 Classifica=on of An=bacterials

β-Lactam An7bio7cs β-Lactam An7bio7cs

Cephalosporins Bacampicillin (Spectrobid)
First-generaAon Penicillinase-Resistant Penicillins
Cefadroxil (Duricef) Isoxazolyl penicillins (dicloxacillin, oxacillin,
Cefazolin (Ancef) cloxacillin)
Cephalexin (Keflex) Nafcillin (Unipen)
Second-generaAon CombinaAon with β-lactamase Inhibitors
Cefaclor (Ceclor) Augmen7n (amoxicillin plus clavulanic acid)
Cefamandole (Mandol) Unasyn (ampicillin plus sulbactam)
Cefonicid (Monocid) Zosyn (piperacillin plus tazobactam)
Ceforanide (Precef) Aminoglycosides
Cefotetan (Cefotan) Amikacin (Amikin)
Cefoxi7n (Mefoxin) Gentamicin (Garamycin)
Cefprozil (Cefzil) Neomycin (Mycifradin)
Cefuroxime (Zinacef) Ne7lmicin (Netromycin)
Cefuroxime axe7l (Cebin) Streptomycin
Third-generaAon Tobramycin (Nebcin)
Cefdinir (Omnicef) Protein Synthesis Inhibitors
Cefditoren (Spectracef) Azithromycin (Zithromax)
Cefixime (Suprax) Clarithromycin (Biaxin)
Cefotaxime (Claforan) Clindamycin (Cleocin)
Cefpodoxime proxe7l (Van7n) Chloramphenicol (Chloromyce7n)
Table 56-4 In Vitro An=microbial Suscep=bility: Aerobic Gram-Posi=ve Cocci
Staph Staph
Staph aureus Staph epidermidis Streptococc Enterococci Pneumococ
Drugs aureus (MR) epidermidis (MR) ia b ci
Ampicillin + + + + + + + + + + +
Augmen7n + + + + + + + + + + + + + + + + + + +
Aztreonam
Cefazolin + + + + + + + + + + + + + +
Cefepime + + + + + + + + + + + + + + +
Cefoxi7n/ + + + + + + +
Cefotetan
Cefuroxime + + + + + + + + + + + + + + +
Ciprofloxaci+ + + + + + + + + + + + + +
nc
Clindamyci + + + + + + + + + + + + + + + +
n
Cotrimoxaz + + + + + + + + + + + + + +
ole
Daptomyci + + + + + + + + + + + + + + + + + + + + + + + + + + + +
nf
Erythromyc + + + + + + + +
in
Table 56-5 In Vitro An=microbial Suscep=bility: Gram-Nega=ve Aerobes
Pseudomo Haemophi
Klebsiella Enterobac SerraAa nas Haemophi lus
Escherichi pneumoni ter Proteus marcesce aeruginos lus influenzae
Drugs a coli ae cloacae mirabilis ns a influenzae a
Ampicillin + + + + + + + + +

Augmen7 + + + + + + + + + + + + + + + + +
n

Aztreona + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
m

Cefazolin + + + + + + + + + + +

Cefepime + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Cebazidim+ + + + + + + + + + + + + + + + + + + + + + + + + + + + +
e

Cefuroxim + + + + + + + + + + + + + + + + + + +
Table 56-6 An=microbial Suscep=bility: Anaerobes
Peptostreptococcu
Drugs Bacteroides fragilis Peptococcus s Clostridia
Ampicillin + + + + + + + + + + + +
Aztreonam
Cefazolin + + + + + +
Cefepime + + + + + + + +
Cefotaxime + + + + + + + + +
Cefoxi7n + + + + + + + + + + +
Cebazidime + + +
Cebizoxime + + + + + + + + + +
Ciprofloxacin + + + +
Clindamycin + + + + + + + + + + + + +
Moxifloxacin + + + + + + + + + + +
Imipenem + + + + + + + + + + + + + +
(Doripenem/
Ertapenem/
Meropenem)
Metronidazole + + + + + + + + + + + +
Penicillin + + + + + + + + + + + + +
 Penetrasi An7bio7ka
Penetrasi Antibiotika
Chloramphenicol, metronidazole, Rifampicin,
CNS Kotrimoksazol (sangat baik)
Penicillin & derivatnya, gol carbapenem, cefepime,
cefotaxime, ceftazidim, ceftizoxim, ceftriaxon,
cefuroksim, ciprofloxacin, ofloxacin (baik)
Aminoglikosida, azithromycin, clarithromycin,
clindamycin, erythromycin, vancomycin (kurang-
buruk)

Cefazolin (sangat baik, hanya untuk

Tulang
profilaksis bedah), Cefuroxim, Ampicilin
Sulbactam
Kotrimoksazol, fluoroquinolon
Prostat
 Penetrasi Aminoglikosida
Tempat infeksi Tingkatan Penetrasi
Mata Poor
CNS Poor (<25%)
Pleural Excellent
Bronchial Secre7ons Poor
Sputum Fair (10-50%)
Pulmonary 7ssue Excellent
Asci7c Fluid Variable (43-132%)
Peritoneal fluid Poor
Bile Variable (25-90%)
Bile with obstruc7on Poor
Synovial fluid Excellent
Bone, Prostate Poor
Urine, Renal 7ssue Excellent
 Dosis Aminoglikosida
•  Berikan loading dose, 7dak peduli fungsi
ginjal: Gentamicin 2mg/kg, Tobramycin 2mg/
kg, Amikacin 7,5mg/kg
•  Maintenance dose diperhitungkan
berdasarkan perkiraan klirens krea7nin
•  Maintenance: once daily: efek7f secara
farmakodinamik, nefrotoksisitas minimal,
ototoksisitas belum diketahui.
 Dosis Aminoglikosida
•  Berikan loading dose pada sepsis, 7dak perduli
fungsi ginjal: Gentamicin 2mg/kg, Tobramycin
2mg/kg, Amikacin 7,5mg/kg
•  Maintenance dose diperhitungkan
berdasarkan perkiraan klirens krea7nin
•  Maintenance: once daily: efek7f secara
farmakodinamik, nefrotoksisitas minimal,
ototoksisitas belum diketahui.
 Common Misuses of An=bio=cs

•  Prolonged Empiric An=microbial Treatment

Without Clear Evidence of Infec=on.
•  Treatment of a Posi=ve Clinical Culture in the
Absence of Disease.
•  Failure to Narrow An=microbial Therapy When
a Causa=ve Organism Is Iden=fied.
•  Prolonged Prophylac=c Therapy
•  Excessive Use of Certain An=microbial Agents.
Preven=ng Emergence of An=bio=c
Resistance

•  The widespread—and oben inappropriate—use of

an7microbial agents is the single most important
cause of the emergence of drug resistance, both in
the community and hospital seongs.
•  Prior an7bio7c exposure has been shown to be the
most frequent risk factor for the development of
community-acquired respiratory infec7ons caused by
drug-resistant S pneumoniae.
•  the emergence of an7microbial resistance can be
prevented or delayed through judicious prescribing,
 Pencegahan Resistensi
•  Kemungkinan terjadinya resistensi ke7ka
menggunakan an7mikroba tergantung pada:
•  Kecenderungan untuk menjadi resisten pada
subpopulasi m.o.
•  Laju mutasi spontan untuk resistensi
an7mikroba
•  Kemampuan pertahanan tubuh untuk
mengontrol pertumbuhan m.o. resisten
•  Kadar an7mikroba di tempat infeksi.
 Pencegahan Resistensi
•  Untuk cegah munculnya subpopulasi m.o yang
resisten kadar an7mikroba plasma harus
berkisar 8-10 kali dari MIC.
•  Hal tersebut dapat dipenuhi dg once daily
dose aminoglikosida, Fluoroquinolon yang
poten, dosis 7nggi β-lactam.
 COMMON ADR
•  Skin rash,ur7karia: Beta Laktam, ciprofloxacin
•  Steven Johnson: Cotrimoxazole
•  Drug-induced hepa77s: Rifampicin, INH,
Flucloxacillin
•  Drug-induced renal disease: aminoglikosida
•  Drug-induced hematology anomali:
chloramphenicol, penicillin
 PEMILIHAN ANTIBIOTIKA PADA
INFEKSI NOSOKOMIAL
q Pemilihan an7bio7ka secara empirik yang tepat
pada awal terapi dapat mengurangi risiko SEPSIS,
KEMATIAN, LAMA TERAPI, menggunakan
ven7lator serta BIAYA HOSPITALISASI.
q Sulit digeneralisasi, mengingat pola sensi7vitasnya
berbeda di se7ap rumah sakit.
q Peran Mikrobiologis untuk menghasilkan
an7biogram sebagai panduan awal
q Perlunya se7ap rumah sakit memiliki Komite
Penggunaan An7bio7ka Rasional di samping
Komite Pengendalian Infeksi Nosokomial (WHO, 2002)
 PRINSIP PEMILIHAN ANTIBIOTIKA INFEKSI
NOSOKOMIAL
q STRATEGI DE-ESKALASI
q KOMBINASI dg AMINOGLIKOSIDA PADA:
Sepsis, bakteremia, demam neutropeni, atau infeksi
oleh Pseudomonas aeruginosa, MDR
q Berikan loading dose bila menggunakan
aminoglikosida, dosis pemeliharaan disesuaikan
fungsi ginjal
q Sesuaikan an7bio7ka dengan hasil kultur segera
q Alihkan an7bio7ka parenteral ke oral segera
setelah kondisi klinik membaik

 LOADING DOSE

Loading Dose (LD): BB = BB ideal

Gentamicin 2mg/kg
Tobramycin 2mg/kg
Amikacin 7,5mg/kg
DOSIS PEMELIHARAAN
Klirens Kreatinin Dosing Interval (jam)
(ml/min)
8 12 24

90 84%
80 80%
70 76% 88%
60 84%
50 79%
40 72% 92%
30 86%
25 81%
20 75%
 ANTIBIOTIKA PADA INFEKSI
NOSOKOMIAL MDR
q Gram-Posi=ve Resistance:
•  MRSA yang berasal dari community, maka pilihan
AB: clindamycin, Cotrimoxazol and tetracycline,
•  MRSA dari rumah sakit, pilihan agen:
Vancomycin. Vankomicin resisten:Linezolid dan
Daptomycin
•  Vancomycin-Resistant Enterococci (VRE):
Linezolid,Daptomycin, Tigecycline.
 ANTIBIOTIKA PADA INFEKSI
NOSOKOMIAL MDR
Gram-Nega=ve Resistance:
•  Klebsiella Pneumonia: Carbapenem,
Fluoroquinolon, Tigecycline
•  Acinetobacter : betalaktam-sulbaktam,
polymixin B+Colis7n, carbapenem.
 CAP
•  CAP adalah pneumonia yang didapat dari rumah
(bukan RS, bukan Nursing House/Pan7 Jompo)
dengan infiltrat yang tampak dengan thorax X-
ray atau auskultasi
•  Faktor Risiko: umur>65 tahun, ashma, COPD, DM,
perokok, CHF, CKD, immunocompromised,
alcohol abuse
•  Sign&Symptoms: demam 7nggi, batuk dengan
atau tanpa sputum,dyspnea, nyeri dada,
wheezing, myalgia, rigors, sweats
 Scoring System
•  CURB-65:predik mortalitas, skor>2
membutuhkan terapi yg intens. Skor 0-5, 1
poin untuk se7ap kondisi berikut:
•  Confusion caused by pneumonia (1)
•  Urea Nitrogen> 19mg/dl (1)
•  RR ≥ 30x/menit (1)
•  TD ≤ 90/60 mmHg (1)
•  Usia ≥ 65tahun (1)
 Treatments
q Goal: eradicate infecting organism, prevent complication &
prevent resistance
q Pathogen: S,pneumoniae, H, influenzae, M. pneumooniae, C.
pneumoniae, Legionella.
q Outpatients:
•  sebelumnya sehat, no AB dalam 3 bulan : Makrolida
(Azithromycin 1x500mg, kemudian 1x250mg (4hari) atau
1x500mg (3hari), Doxycycline 2x100mg
•  DM, alcohol, immunocompromised,COPD, AB dalam 3 bulan:
Levofloxacin, amoxy-clav +makrolida
•  Dugaan aspirasi: amoxy-clav, Clindamycin
•  MRSA (+): + Vancomycin/Linezolid (resisten thd Vancomycin)
q Durasi: 7-10 hari
 Treatments
q Hospitalisasi:
•  sebelumnya sehat, no AB dalam 3 bulan : Makrolida,
Doxycycline
•  DM, alcohol, immunocompromised,COPD, AB dalam 3
bulan: makrolida + amoxy-clav/Cefuroxime/Ceftriaxone
Respiratory fluoroquinolon: Levofloxacin,moxifloxacin,
makrolida + amoxy-clav/Ceftriaxone/Cefuroxime
•  Severe Pneumonia: respiratory quinolon,
makrolida+ceftriaxone/cefotaxime/ampi-sulbac
•  ICU: (Ampi-Sulbac,Ceftriaxone/cefotaxime) + respiratory
quinolon/azithromycin
•  Durasi terapi: 5-10 hari
 HAP/VAP
q Early onset: <5 hari, no risk of MDR:
•  Ceftriaxone
•  Levofloxacin/Moxifloxacin/Ciprofloxacin
•  Ampicilin-Sulbactam
•  Karbapenem
q Late onset>5hari atau risk factor MDR(+):
•  (Ceftazidime or Cefepime) + aminoglikosida/Fluoroquinolon
(Cipro/Levo)
•  Piperacilin-Tazobactam + aminoglikosida/aminoglikosida/
Fluoroquinolon (Cipro/Levo)
•  Bila MRSA (+) : + Vancomycin
•  Durasi terapi: 5-7hari
 UTI
•  Predisposing Factors: manula, wanita, DM,
kehamilan, UT instrumentasi, UT obstruksi, ,
disfungsi neurologi, renal diseases
•  Uncomplicated Cys77s: TMP-SMZ (3 hari),
Fluoroquinolon(3 hari), nitrofurantoin (7hari),
Fosfomycin (1hari)
•  Kehamilan: 7 days of Amoxicillin,
nitrofurantoin, cefalexin, TMP-SMZ (hindari
trimester 3)
 UTI
•  Uncomplicated pyelonefri7s: TMP-SMZ 14
days , Fluoroquinolon 5 days
•  Complicated UTI: Fluoroquinolon 5 days,
aminoglycosides, ES-beta Laktam
•  Catheter-related UTI: symtoma7k dg
bakteriuria diterapi 7-10 hari dan lepas
kateter. Asimtoma7k dg bakteriuris tdk perlu
terapi.
 SOFT TISSUE INFECTION

ž CELLULITIS
ž Def: inflamasi akut dari kulit dan lemak subkutan yg ditandai
swelling, warmth, pain, erythema
ž Bakteri:Staphylococcus A, Streptococcus P
ž Immunocompromised: E.Coli, P aeruginosa, Klebsiella P
ž A.B: Cloxacillin, Penicillin, Clindamycin, erythromycin
ž DM: sda + S epidermidis,enterococcus faecalis, E.coli,
Klebsiella, Proteus, Peptococcus, sp, Bacteroides sp
 ANTIBIOTIKA PADA UTI
•  Community •  Nosocomial
•  Bakteri: E Coli, P.mirabilis, CNS, •  Bakteri: E.Coli,
Klebsiella, enterococcus P.aeruginosa,
faecalis. enterobacter, serratia
•  Pilihan: Cotrimoxazol atau •  Pilihan: Ceftazidime atau
amoxi-clav atau fluoroquinolon Ticarcillin-clavatau
selama 3 hari (complicated case Carbapenem atau
7-14hari) Aztreonam
 Infeksi Pada Gagal Ginjal
Leukositosis belum tentu infeksi, karena komplikasi thd
hematologi, sebaiknya cek differential count.
q Macam Infeksi: Pneumonia, ISK
q Penatalaksanaan : AB parenteral, bila harus kombinasi dg
aminoglikosida (hitung dosis dg farmakokinetika formulasi
spesifik)
q Penyesuaian Dosis:
•  Time dependent A.B: kurangi interval
•  Dose dependent A.B: kurangi dosis
q Monitor: Cr, BUN

 Infeksi Pada Chronic Liver Disease
q Infeksi Umum: Spontaneous Bacterial Peritonitis
q Dapat memicu Hepatik Encefalopati
q Penatalaksanaan: AB generasi III, Quinolon +
Albumin parenteral
q Penyesuaian dosis: penurunan dosis mengacu
pada Child Pugh Score dan metabolisme obat.
q Monitor: Transaminase, albumin, ALP
 ANTIBIOTIKA PADA SEPSIS
q Gram Posi7ve Sepsis: Meropenem/Cefoperazon/
cefepime + Cloxacillin (An7-stafilokokus)
•  Bila dugaan MRSA: gan7 cloxacillin →Vancomycin
or Linezolid (Bila resisten thd Vancomycin) or
Daptomycin

•  Bila Coagulase-Nega7ve Staphylococcus (kurang

virulens) gan7 Vancomycin → fluoroquinolon
•  Minimize the use of vancomycin in order to
prevent the emergence of Enterococcus faecium,
a vancomycin-resistant species.
 ANTIBIOTIKA PADA SEPSIS
q Gram Posi7ve Sepsis: Meropenem/Cefoperazon/
cefepime + Cloxacillin (An7-stafilokokus)
•  Bila dugaan MRSA: gan7 cloxacillin →Vancomycin
or Linezolid (Bila resisten thd Vancomycin) or
Daptomycin

•  Bila Coagulase-Nega7ve Staphylococcus (kurang

virulens) gan7 Vancomycin → fluoroquinolon
•  Minimize the use of vancomycin in order to
prevent the emergence of Enterococcus faecium,
a vancomycin-resistant species.
 ANTIBIOTIKA PADA SEPSIS
•  Sumber infeksi biliary-tract: bakteri E. coli,
Klebsiella species, and Enterococcus faecalis.
•  Pilihan : imipenem, meropenem, piperacillin,
or cefoperazone.
 ANTIBIOTIKA PADA SEPSIS
•  Sumber infeksi : lower abdomen and pelvis
•  Bakteri: aerobic coliform gram-nega7ve bacilli and
B fragilis. Enterococci are permissive/opportunis7c
pathogens and do not require special coverage.
Potent an7– B fragilis and aerobic gram-nega7ve
bacillary coverage are essen7al
•  Pilihan: imipenem, meropenem, piperacillin/
tazobactam, or ampicillin/sulbactam.
•  Preferred combina7on therapy for intra-abdominal
and pelvic infec7ons is clindamycin or
metronidazole plus aztreonam, levofloxacin, or an
aminoglycoside.
 UROSEPSIS
•  Bakteri: gram-negative aerobic bacilli, eg, coliforms or
enterococci (E faecalis, not E faecium vancomycin-resistant
enterococci).
•  Pseudomonas aeruginosa, Enterobacter species, and
Serratia species are rare uropathogens and are associated
with urological instrumentation.
•  Pilihan : aztreonam, levofloxacin, third- or fourth-generation
cephalosporins, or an aminoglycoside.
•  Empiric therapy for community-acquired urosepsis is
levofloxacin, aztreonam, or an aminoglycoside plus
ampicillin.
•  For nosocomial urosepsis, piperacillin-tazobactam,
imipenem, or meropenem monotherapy is preferred.
 Superinfeksi
•  Akibat pemakaian an7bio7ka spektrum luas dalam
jangka waktu lama.
•  Mikroorganisme penyebab umumnya adalah jamur,
sehingga terapi yang harus diberikan adalah preparat
an7jamur parenteral (Fluconazole 2 x 400mg hari
pertama, selanjutnya 2 x 200mg).
•  Terapi dapat dihen7kan setelah demam menghilang,
dilanjutkan dengan fluconazole oral hingga total
terapi 14 hari atau bebas kandida
 SWITCH ANTIBIOTICS
•  Mulai setelah tanda klinik membaik
•  Lebih cepat lebih baik kecuali pada neutropenic fever
•  Peralihan ke AB oral yang mempunyai spektrum sama
dengan AB parenteralnya
•  Peralihan 7dak harus dalam golongan & generasi AB
yang sama
•  Pilih AB oral yang mempunyai bioavailabilitas baik
Table 5. Agents used in empirical intravenous-to-oral switch therapy
Infection Intravenous agent* Oral agent*

Acute bacterial Ceftriaxone sodium Chloramphenicol

meningitis

Community-acquired
pneumonia
•  Typical** Ceftriaxone Doxycycline
or ceftizoxime sodium or azithromycin
or levofloxacin or levofloxacin
or cefuroxime axetil
or cefixime
•  Atypical Doxycycline Doxycycline
or erythromycin or azithromycin
or levofloxacin or levofloxacin
•  Response to treatment of an infec7on can be assessed
using both clinical and microbiological parameters.
•  Clinical parameters decrease in fever, tachycardia, or
confusion), laboratory values (eg, decreasing leukocyte
count), and radiologic findings (eg, decrease in the size
of an abscess).
•  radiologic improvement can frequently lag behind
clinical improvement, and rou7ne radiographic follow-
up of all infec7ons is not always necessary.
•  Persistent bacteremia can also be associated with the
emergence of an7microbial resistance and should
always be inves7gated

Assessment of Response to Treatment

 10. Pemberian informasi kepada

•  Penderita
–  Penggunaan yang benar
–  Efek samping
•  Perawat / staff lain
–  Dosis
–  Sediaan
–  Cara pemberian
–  Monitoring efek samping
76
 Thank you
•  It is the end of the road for anAbioAcs unless
we act urgently. Tom Frieden