Prof. Dr. Kuntaman,dr.

,MS,SpMK(K)

• Advisor KPRA KEMENKES R.I

• Advisor KPRA RSUD
Dr.Soetomo
• Ka.Prodi Magister/S2 Ilmu
Kedokteran Dasar FK UNAIR
• Ketua Dewan Etik FK UNAIR
• Ketua PAMKI Pusat
 Optimalisasi pelayanan mikrobiologi
klinik pada manajemen infeksi
Optimizing of Clin Microbiology Services in
management of Infection

Kuntaman
Department of Microbiology
Faculty of Medicine - Dr. Soetomo Hospital
Universitas Airlangga -Surabaya
Komite PPRA Kemnterian Kesehatan R.I.

Pelatihan Reviewer Penggunaan antibiot di RS

KPRA Surabaya, 26-27 Jan 2018
 CASE-1
Day-1:
• Male, 23 y.o.
• Sub-bacterial Endocarditis
Septum vegetation (USG)
Sepsis: Tem. 39 C, Leu: 17.000/dl
• Ther: CRO 2 dd 1 gram
• Blood culture D/S: Send to Clin Micro
 CASE-1
Day 4:
Result Micro BACTEC: Sta aureus (D/S)
• Res: P, AMP
• Sen: FOX, SXT, ERY, VA, AMC, DA, RIF
Send to Dep. Cardiology

Day 5: Consult to Clin Micro

• Patient plan to Cardiac surgery for Valve
replacement
• How about: AB vs Culture result
 CASE-1
Day 5: Consult to Clin Micro
• Discuss
• Prudent: ?  Gyssen Criteria

① Pts Infection: ?
② Ab: ?
③ Surg Proph: ?
④ Ab for Surg Intervention: ?
 INTRODUCTION
• The clinical microbiologist has places for its
fundamental task according to the health
care services (Finch et al, 2005):
– the clinical microbiologist should remain entirely
laboratory based: Performe microbiological
examination
– a physical presence of the clinical
microbiologist within the clinical areas (Wards):
together with clinician make interpretation &
determine of therapeutic policy

Finch, R., Itrymewicz, W. and van Eldere, J. 2005. Report of working group 2: Health care needs in
the organization and management of infection. Clin Microbiol Infect; 11(Suppl.1):41-45
6
 Without direct consultation,
recommendation are followed in 39%
cases
– Because the clinician will not change based
on a report alone

Diagn. Micro.Infect.Dis, 91;14:157-66

7
 CASE-2
Day-1:
• Male, 64 y.o.; Adm. To DSHS
• Acute Pancreatitis (D-9) & Shock Septic (Post
Hospitalization in Sec Hosp);
 Post Ther Meropenem for 9 days
• Temp. 39 C
• Leucocyte: 16.940/dl
• Amilase/Lipase: > 1000 / > 1000
• AB: change to SCF
• Blood Culture  Lab Micro
 CASE-2
Day-4:
• Temp. 39 C
• Leucocyte: 16.610/dl
• AB: SCF
• Blood Culture D/S: No growth
 CASE-2
Day-13:
• Temp. 38-39 C; Leucocyte: 10.990/dl
• PCT: < 0.05; Lactate: 7 mg/dl
• AB: SCF  STOP
• Plan: FNAB Guiding CT Scan or MRI

Day-15:
•Septic ‘AGAIN’; Tem. 39 C
•Leucocyte: 16.000/dl; PCT: > 100
•AB: SCF again
•Team ICU-PPRA: Case: Discussion
 Kasus Sulit:
1. Pemeriksaan Mikrobiologi

2. Pelayanan Mikrobiologi Klinik

• kerjasama: AB Prudent vs Non-Prudent
• Interpretasi lebih terarah
• Patient Savety
• Ther empirik
 Terapi Empirik:
1. AB yang paling kuat: ???
2. Dosis setinggi mungkin: ??
 Siapa yang menentukan AB terkuat
untuk infeksi tertentu: ??
ATS Guideline

1. Empirical therapy: should be

based Local data Micro culture
2. Invasive sampling OR Non-invasive
sampling-semi-quantitative
3. PCT/CRP: are needed for Evaluation
of improvement
 ATS Guideline for Empirically ther

1. For S aureus/MRSA: ??
 Local Evidence:
 MSSA: LEV, FEP, PTZ, MEM
 MRSA: VAN, LZD

What next: ???

Apa yg kita perbuat dgn guideline tsb
 CASE-3

Mrs. Z, 39 y.o., Teacher

• Referred to Dr Soetomo Hosp SBY
• Short breathness, Cough, Sputum++,
Fever;

CAP
 Laboratory Examination
BLOOD Blood Gas Analysis
10/12/15 Hb 13/12/15 pH 7. 58
: 12.8 Ureum : 44 mg/dL pCO2 36,3
SC : 0,51mg/dL
WBC : 4.8 pO2 53,3
Alb : 4.06mg/dL
Gran : 84% HCO3- 29,5
Plt : 219.000 BE 6,6
SaO2 91%
Sputum GRAM:
Leu: scarse
Bacterial: not dominant

Antibiotic: MEM & AK: ??

 Prudent Use AB vs
Services on Clin Microb
To optimize of AB Use base on Services in
Clin Microb:
① Indication Clin Micr.
② Not Prudent due to: ?? (Alternative) Services

③ Not Prudent due to: ?? (Dose) Clin Pharm.

Services
④ Not Prudent due to: ?? (Time)
⑤ Prudent Use AB
 Antibiogram
• Empiric ther
• Highest probability bacterial causative agent &
AST
• Validity of AB-gram

• Empiric: Prudent vs Non prudent

• Up to 3 days: too long vs too short
 HAP
Antibiogram ICU, Sputum, 2014, Dr Soetomo Hosp

Microbes Quant %
80%
Ac baumannii/compl. 129 41%
Pseu aeruginosa 67 21%GN
98%
K. pneumoniae 56 18%
E coli 26
Burkholderia cepacia 15
Stenotropo maltophilia 7
Enter cloacae 7
Enter aerogenes 5
Staphy aureus 6 2%
Total 318
 ICU - Sputum
Bacteria Ac baum Ac.baum/calc Ps.aeru E coli Kl.pneumo
n Sen% n Sen% n Sen% n Sen% n Sen%
AK 83 40 48 29 67 58 26 100 56 93
GEN 83 20 48 59 67 49 26 58 56 57
TOB 83 30 48 29 67 43 26 46 56 50
CIP 83 18 48 8 67 48 26 15 56 39
LEVO 83 18 48 8 67 52 26 23 56 71
AMP 83 0 48 0 67 0 26 0 59 0
AMC 83 0 48 0 67 0 26 4 59 25
AZT 83 0 48 0 67 27 26 4 59 19

FOX 83 0 48 0 67 0 26 38 59 66
CEFA 83 0 48 0 67 0 26 4 59 14
CTX 83 4 48 2 67 0 26 4 59 24
CRO 83 11 48 6 67 0 26 4 59 17
CAZ 30 87 26 4
PTZ 83 13 48 4 67 57 26 58 59 51
FEP 83 13 48 4 67 43 26 4 59 85
ERTA 83 0 48 0 67 0 26 58 54 63
IMI 83 43 48 23 67 49 26 96 55 84
MEM 83 39 48 25 67 57 26 96 55 95
TET 83 28 48 23 67 0 26 19 56 54
SXT 83 39 48 29 67 0 26 4 56 36
 Para-pneumonic Pleural Effusion
• Pleural effusion due to any causes
– Bacterial Pneumonia
– TB
– Antigenic induce
• Lab:
– Micro-Gram staining & Acid Fast Staining
– Chemical
Staging
1. Exudative stage
2. Fibrino-purulent stage
3. Organization stage
 Case-4:
Parapneumonic Effusion = PPE

16 y.o. Female
Referred to Dr Soetomo Hosp SBY
Complicated PPE
 Time line of the patient
Admission in Sec Ref Hosp
USG of thorax : multi loculated
Admission RSDS pleural effusion in minimal
Pl Fluid &
(S) Culture Fluid: S.pneumoniae + AST &
WSD Sput: K.Pneumoniae + AST

5/4/17 9/4/17 11/4/17 13/4/17

14/4/17 18/4/17
03/5/17

Merop 1 g/8 h iv Out of hospital

(13 days)
Metro 500 mg/ 8
h iv (9 days)
Levo 750 mg/ 24 h drip
 Microb Lab result
Date Specimen Micro Result AST
11/4, Pus of Strep pneu Sen : C, LEV, FOS,
2017 pleura ERY,DA, Pen G
Sputum Kleb pneu Sen : AK,TOB, CN,
ATM, AMC, CAZ, CTX,
SCF,SXT, C, CIP, LEV,
????? IMP, ETP
13/4, Sputum GeneXpert MTB not detected
2017
 SUMMARY
1. Diagnosis of Inf Dis: the most important first
step in management of infectious dis.
2. The rational use of the local data should be
based for Inf Managemet
3. Micro culture  is mandatory  for best
practices in management of Infection
4. The hospital should increase the services on
Clin Microb rather than technical aspect
5. The services on Clin Microb can start in the
first day of the patient care
 SUMMARY
6. The Power of GRAM staining & Blood
routine can solve most cases.
7. How to assess or to judge the prudent use
of antibiotic, need the multi-professional
support, such as Clin Microbiology, Clin
Pharmacy, etc

The strengthening of clin mcrob services, is

absolutely needed for improving the quality of
health services, especially in Inf Dis.
[Teaching Hosp, Ref. hosp]