Komite Pengendalian Resistensi Antimikroba

KEMENTERIAN KESEHATAN R.I

MENGAPA PERLU PROFILAKSIS ?
dokter takut kalau infeksi
beban perasaan dokter
reputasi dokter
pasien menderita
beban biaya

dokter ikut pengalaman yang lalu

operasi = profilaksis
pelajaran saat PPDS I
ikut seniorny

Pasien yang meminta Antibiotik

mengganggu tugas dan penghasilan
 Kasus Usia
Ko-morbid
Instrumentasi Instrumen
Status umum
pasien
Air bersih
Sarana OK
Infeksi Daerah Operasi
Koloni OK antiseptik

SDM
Cuci tangan SOP Antibiotik

kompetensi Linen Pasca operasi

Operator
 suntikan oral
DULU Pre op (+) (-)

Post op Sampai flatus 5-7 hari

penggunaan
Amoksisilin clav
antibiotik Ampisilin,
saat operasi Sulbenisilin
Sefotaksim, Amoksisilin Clav
Jenis Seftriakson Erythromisin
Seftasidim Sefadroksil
Gentamisin, Clindamicin
Nitromisin,
Tobramisin
Dampak .....
Antibiotik Profilaksis diberikan kurang tepat
jenis, dosis, kombinasi dan lamanya
Pemahaman Profilaksis dan terapi
rancuh
penggunaan antibiotik berlebihan
memicu resistensi bakteri
beban biaya meningkat
 Tujuan Sesi
1. Memahami definisi dan ruang lingkup penggunaan antibiotik profilaksis
2. Mengetahui kriteria infeksi luka operasi
3. Mampu melakukan monitoring dan parameter penggunaan antibiotik
profilaksis
4. Memahami pembagian kriteria kelas operasi dan status fisik penderita
5. Memahami kemungkinan kejadian IDO
6. Memahami cara penggunaan antibiotik profilaksis
7. Memahami SPO pemberian antibiotik profilaksis
8. Memahami rekomendasi pemberian antibiotik profilaksis berdasarkan
level and grade of evidence
9. Mampu melakukan follow up penggunaan antibiotik profilaksis
10. Mampu menentukan pilihan antibiotik profilaksis yang sesuai dengan
jenis tindakan pembedahan
Definitions :
Antibiotik yang diberikan sebelum-saat-setelah operasi pada kasus
yang secara klinis tidak terdapat tanda infeksi. Tujuannya untuk
mencegah terjadinya ILO / SSI / IDO dan mencegah kolonisasi

Infection here may cause:

Delayed healing

Hernia
Possible evisceration

Abscess
Fistula
Other procedures needed
 Keuntungan dan Keterbatasan
penggunaan antibiotik profilaksis

Keuntungan Antibiotik Profilaksis

Menurunkan infeksi luka operasi dan morbiditas
Menurunkan biaya perawatan
Mengurangi lama tinggal di rumah sakit

Keterbatasan Antibiotik Profilaksis

Meningkatnya resiko kolitis karena Clostridium difficile
bila menggunakan sefalosporin generasi III
Meningkatnya frekuensi bakteremia pada penderita
yang memakai antibiotik profilaksis lebih dari 4 hari
dibandingkan dengan yang mendapat profilaksis 1
hari
 Dosis Tunggal v/s Multipel
Fakta
laporan

Single-dose versus multiple-dose antibiotic

prophylaxis for the surgical treatment of closed
fractures .
Slobogean.et.al. Acta Orthopaedica 2010; 81 (2): 256262
 Treating > 48hrs:
More resistant bugs
Impact of Higher cost

Prolonged
Antibiotic
2,641 op by past art. Coronarius jantung
Prophylaxi
Group 1 <48 jam of antibiotics
s Group 2 >48 jam of antibiotics

SSI rates
Group 1 9% (131/1,502)
Group 2 9% (100/1,139)
Odds ratio 1.0 (95% CI: 0.81.3)

Peningkakatan resitensi pada group 2:

Odds ratio 1.6 (95% CI: 1.12.6)

CABG = coronary artery bypass grafting; CI = confidence interval.

Harbarth S et al. Circulation. 2000;101:29162921.
 kolonisasi

Antibiotika profilaksis
 Kelas
operasi
(Mayhall) Bersih
Operasi tidak melibatkan
saluran cerna, urinarius,
vagina

Bersih terkontaminasi
Operasi melibatkan saluran
cerna, urinarius, vagina
Tidak terdapat tanda klinis
infeksi
 Indikasi Kasus operasi bersih dan
Antibiotik bersih kontaminasi
Pada operasi bersih
Profilaksis Diberikan apabila berisiko
komplikasi lebih merugikan
infertilitas, operasi
jantung
Pemasangan
implant/benda
asing
Skor ASA
Kemungkinan terjadi IDO
 Pemilihan jenis antibiotik profilaksis

Jenis antibiotik
Paling efektif menghambat pertumbuhan mikroba kolonisasi
Toksisitas rendah
Golongan paling rendah yang masih efektif menekan pertumbuhan
koloni (Golongan sefalosporin generasi I atau generasi 2)
Dosis dan lama pemberian
Dosis sama dengan terapeutik
Pemberian tunggal (sekali pemberian), banyak penelitian menjelaskan
pemberian 1 kali sama efektifnya dengan pemberian 3 kali
Lama pemberian tidak melebihi 24 jam
Results: A total of 540 patients were recruited; (females73.7% of total ). The
performed surgical procedures were 547. The rate of wound infection was
10.9%. Multivariable logistic analysis showed that; ASA score > 3; (p= <0.001),
wound class (p= 0.001), and laparoscopic surgical technique; (p= 0.002) were
significantly associated with prevalence of wound infection. Surgical prophylaxis
was unnecessarily given to 311 (97.5%) of 319 patients for whom it was not
recommended. Prophylaxis was recommended for 221 patients; of them 218
(98.6 %) were given preoperative dose in the operating rooms. Evaluation of
prescriptions for those patients showed that; spectrum of antibiotic was
adequate for 160 (73.4%) patients, 143 (65.6%) were given accurate doses,
only 4 (1.8%) had the first preoperative dose/s in proper time window, and for
186 (85.3%) of them prophylaxis was extended post-operatively. Only 36 (6.7%)
prescriptions were found to be complying with the stated criteria.
Conclusion: The rate of wound infection was high and prophylactic antibiotics
were irrationally used. Multiple interventions are needed to correct the situation.
Results: Perioperative antibiotic prophylaxis was appropriate in 18.1% of
cases. The multivariate logistic regression analysis showed that patients with
hypoalbuminemia, with a clinical infection, with a wound clean were more likely to
receive an appropriate antibiotic prophylaxis. Compared with patients with an
American Society of Anesthesiologists (ASA) score 4, those with a score of 2 were
correlated with a 64% reduction in the odds of having an appropriate prophylaxis. The
appropriateness of the timing of prophylactic antibiotic administration was observed in
53.4% of the procedures. Multivariate logistic regression model showed that such
appropriateness was more frequent in older patients, in those admitted in general
surgery wards, in those not having been underwent an endoscopic surgery, in those
with a higher length of surgery, and in patients with ASA score 1 when a score 4 was
chosen as the reference category. The most common antibiotics used
inappropriately were ceftazidime, sultamicillin, levofloxacin, and
teicoplanin.
Conclusions: Educational interventions are needed to improve
perioperative appropriate antibiotic prophylaxis.
Results:
the study involved 21 wards of 4 Public hospital
Of the 320 cases collected, 63 were excluded; of the
remaining 257 cases, 56.4 % of the procedures
were appropriate (score 4), 15.2 %
acceptable and 28.4 % were not acceptable.
were
The study found an unjustified continuation of
antimicrobial prophylaxis in 17.1 % of the 257 cases, an
unjustified re-start of antimicrobial therapy in 9.7 % and a
re-dosing omission in 7.8 %.
Persiapan pasien operasi
 Elective
Surgical
Procedures 80 mg/dl> Gluc. Darah <110mg/dl akan
menurunkan:
Prevention of ICU mortality (8%-4.6%)
Hyperglycemi Sepsis (46%)
a ARF requiring HD (41%)
RBC transfusion (50%)
Polyneuropathy (44%)
Independent variable with
conventional
care
Volume 345:1359-1367 November 8, 2001 Number 19
Intensive Insulin Therapy in Critically Ill Patients
Greet Van den Berghe, M.D., Ph.D., Pieter Wouters, M.Sc., Frank Weekers, M.D.,
Charles Verwaest, M.D., Frans Bruyninckx, M.D., Miet Schetz, M.D., Ph.D.,
Dirk Vlasselaers, M.D., Patrick Ferdinande, M.D., Ph.D., Peter Lauwers, M.D.,
and Roger Bouillon, M.D., Ph.D.
 Glucose control (200 mg/dl)
decreases infection rate

SSIs and Glucose Levels CTS pts

8
6.7%
7
Deep Infection Rate,

6
P=0.002
5
4
2.5%
3 1.3% 1.6%
2
1
%

0
100150 150200 200250 250300
Day 1 Blood Glucose (mg/dL)

Zerr KJ et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations, page 360.
Reprinted from The Annals of Thoracic Surgeons, Vol. 63.
 Elective 200 CRS patients
Surgical Control: Routine intraoperative
thermal care
Procedure (mean temperature 34.7C)
s
Perioperative Treatment: Active warming
Normothermia (mean temperature 36.6C)

I
n Control 19% (18/96)
Warm Patient Strategies:
Start with warm room c Treatment 6% (6/104);
Use Bair Hugger
Cool room for procedure
i P=0.009
cold patients
Use 40o irrigation d had 3x infection
Warm room on closing
GOAL : >36oC (98.6oF) e rate
n
c Kurz A et al. N Engl J Med. 1996;334:12091215.
 Elective
Surgical 500 CRS patients
Procedures 80% or 30% inspired oxygen during
operation and for 2 hours post surgery
Supplemental
Oxygen All patients received prophylactic
antibiotics
Results
Arterial and subcutaneous PO higher in 2

80% oxygen group

Lower incidence of SSIs with higher
Oxygen Strategy:
supplemental oxygen (5.2% vs 11.2%;
Supplemental O2
for 2hrs in RR
P=0.01)
low O2 2x infection
rate
Greif et al. N Engl J Med. 2000;342:161167.
Pencegaha Menjelang Operasi
n infeksi
terkendali Tidak gelisah
Tidur cukup
R/ Sleep inducer
Pasien mandi bersih dengan
sabun
 Elective
Surgical
Procedures
Hair Removal Clipping hair just before case is best

Hair Removal Infection Rate

Method
sore / kerok/shaving 5.2 - 8.8%
pagi / kerok 6.4 - 10%
sore / cukur 4 - 7.5%
pagi / cukur 1.8 - 3.2%

Alexander JW, et al. Arch Surg 1983; 118:347-352

 Syarat masuk kamar operasi
Pencegaha
Cap
n infeksi
Masker
terkendali
Celemek
Hand scrubing
Gaun
Sarung tangan /glove
Antisepsis lapangan operasi
iodophore / chlorheksidine
 Jenis antibiotik profilaksis
Cephalosporin gen I II
Pemberian Cephazolin (1 gr)
Antibiotik Cefuroxime (1-1.5 gr)
profilaksis Pada kasus alergi Cefalosporin
Ampisilin sulbaktam (1 gr)
Amoksisilin as. Klavulanat (1 gr)
Gentamisin (5-8 mg/kg BB)
Pada kasus bedah digestif
KombinasiMetronidazole ( 500 mg)
Pada kasus bedah saraf (penetrasi BBB)
Ceftriaxon (1-2 gr)

28
 Timing Insisi
6
5
4
SSI (%)

3
2
1
0
2 0 2 4 6 8 10

hour
s Harbarth et al, Circulation 2000
Classen et al. N Engl J Med 1992
 30-60 menit sebelum insisi
Intravenous drip
(dilarutkan dalam 100 ml normal saline)
Lama pemberian 15-30 menit
Dosis tunggal max 24 jam
Tidak perlu skin test ?
Antibiotik profilaksis tambahan / ulangan
( max 24 jam )

Lama operasi > 3 jam

Perdarahan > 1500 ml

Konsentrasi di jaringan menurun

31
 ANAPHILAKSIS
Angka kejadian 0.0025 % (25/1.000.000) pada
pemberian gol. Penisilin
36 % diketahui allergy terhadap penisilin
64 % tidak ada riwayat allergy
(Clinical Medicine & Research Volume 8, Number 2: 80-
81, 2010 Marshfield Clinic. Clinmedres.org)
 ANAPHILAKSIS
Reaksi silang anaphilaksis antara gol. Penisilin terhadap
cephalosphorin 10 %
Pasien dengan riwayat setelah mendapat gol.
Penisilin
berisiko terjadi pada pemberian beta lactam (C)
Anaphylaxis
laryngeal oedema
Bronchospasm
Hypotension
local swelling
Urticaria , pruritic rash
(SIGN. antibiotic prophylaxis in Surgery . 2008.)
 Penggunaan antibiotika profilaksis
di Dep/SMF. Obstetri Ginekologi RSU. Dr. Soetomo.
Fakta (AMRIN 2003- 2004)
Study
AMRIN Operasi Angka ILO
Histerektomi Sub Total 0/46

Histerektomi Total 1/277

 Kasus & Prosedure Antibiotik Evidence
Level
Odd.Rt

antibiotik Sectio Cesarea HR 1 0.41

Histerektomi TAH / TVH R 1 0.17
profilaksis Tonsilectomy NR 1
Luka pada wajah NR 1
Partus normal + NR 1
episiotomi
Strumecomy NR 1 -
Ca Mammae R 1
Appendectomy HR 1 0.58
Colorectal surgery HR 1
Hernia NR 1
TUR prostate HR 1
Arthroplasty HR 1
Pemasangan kateter NR 1
Semoga Terhindar dari IDO

Komite Pengendalian Resistensi Antimikroba

KEMENTERIAN KESEHATAN R.I