PERAN PATOLOGI KLINIK

dalam PPRA;
DIAGNOSTIC STEWARDSHIP

Ida Parwati

Department of Clinical Pathology and Laboratory Medicine

Dr. Hasan Sadikin General Hospital – Faculty of Medicine Universitas Padjadjaran
Indonesian Association of Clinical Pathologist and Laboratory Medicine

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Pokok Bahasan
• Situasi Global AMR:
- World Antibiotic Awarenes Week 2018:12-18 Nov
- ‘ONE HEALTH’
• Regulasi :
- PMK No 8 Tahun 2015
- PMK No 2406 Tahun 2011
- SNARS: Standar Nasional Akreditasi Rumah Sakit
• Peran Laboratorium dalam PPRA
• Langkah langkah manajemen PPRA oleh DSPK

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Change Can’t Wait. Our Time with Antibiotics is Running Out

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AMR: ‘ONE HEALTH’

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• Cumulative antimicrobial susceptibility reports (CASRs) (Antibiogram)
• Enhanced culture and susceptibility reports,
• Guidance in the preanalytic phase,
• Rapid diagnostic test availability,
• Provider education,
• Alert and surveillance systems

Philippe Morency-Potvin,a,b,c David N. Schwartz,a,b Robert A.

Weinsteina,b
Clinical
20181129 PPRAMicrobiology
CP_BDG Reviews, January 2017 Volume 30 Issue8 1
Philippe Morency-Potvin,David N. Schwartz, Robert A. Weinstein
Clinical Microbiology Reviews, January 2017 Volume 30 Issue 1
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Action is needed!
From GAP to NAP

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 The NAP indicators:
seven focus areas
1. National AMR Action Plan in line with GAP AMR
2. National AMR surveillance system
3. Antimicrobial Stewardship and Surveillance of
antimicrobial use
4. Infection Prevention Control in healthcare settings
5. Awareness raising
6. Research & innovation
7. One-Health engagement.

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The five strategic objectives of NAP

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JCI

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SNARS

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 PPRA
PROGRAM PENGENDALIAN
RESISTENSI ANTIMIKROBA

PMK Pedoman
PPRA di RS

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Standar Nasional Akreditasi Rumah Sakit
(SNARS) 2018

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© World Health Organization 2016
What is “diagnostic stewardship”
1. The diagnostic pathway
1.1. Specimen selection and collection
1.2. Turn-around time
1.3. Storage and transport
1.4. Summary of pre-analytical specimen management at point-of-care
1.5. Laboratory processing and procedures
1.6. Feedback and reporting of results
2. Organizational aspects of diagnostic stewardship
2.1. Pre-requisites for diagnostic stewardship
2.2. Assessment of conditions for implementation of diagnostic
stewardship at the surveillance site
2.3. Resources and budget
2.4. Roles and responsibilities
2.5. Communication
2.6. Training
2.7. Monitoring and evaluation of the diagnostic stewardship
programme
Diagnostic stewardship is defined in the
GLASS Manual as:

“coordinated guidance and interventions to improve

appropriate use of microbiological diagnostics to guide
therapeutic decisions. It should promote appropriate,
timely diagnostic testing, including specimen collection,
and pathogen identification and accurate, timely reporting
of results to guide patient treatment.”
• The main objective of microbiological diagnostic stewardship is to
deliver:
• patient management guided by timely microbiological data to
deliver safer and more effective
and efficient patient care; and
• accurate and representative AMR surveillance data to inform
treatment guidelines, and AMR
control strategies.
Tim Pelaksana PPRA di Rumah Sakit

Ketua; seorang klinisi yang berminat di bidang infeksi

Anggota;
1. Klinisi perwakilan SMF/bagian
2. Keperawatan
3. Instalasi farmasi
4. Laboratorium mikrobiologi klinik
5. Komite/tim Pencegahan Pengendalian Infeksi (PPI)
6. Komite/tim Farmasi dan Terapi (KFT)

6 PILAR
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 6 PILAR DAN TUGASNYA a.b bijak, panduan,
evaluasi a.b

Panduan a.b, SMF

kepatuhan, evaluasi
Keperawat
KFT
an
Kewaspadaan std,
pemberian a.b
benar, specimen col.
Kewaspadaan std,
surveilans, isolasi,
PPI Farmasi
KLB MDRO

Lab Penyediaan a.b,

mikrobiologi kajian resep,
Pelayanan, evaluasi
konsultasi, penggunaan
antibiogram

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PPRA
• PMK No. 8 tahun 2015 tentang PPRA: Hal hal penting
yang berhubungan dengan laboratorium:
1. Pengendalian penggunaan Ab di RS
2. Tatalaksana KLB MDRO
3. Prinsip pengambilan spesimen mikrobiologi
4. Tahapan pemeriksaan mikrobiologi
5. Konsultasi klinik
6. Pelaporan pola mikroba dan kepekaannya periodik
7. Indikator mutu PPRA
• Kapasitas Lab untuk pengelolaan penyakit infeksi
• Kapasitas lab untuk menunjang PPRA

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PEDOMAN PPRA DI RS YANG MENYANGKUT
LABORATORIUM MIKROBIOLOGI

1. Pengendalian Penggunaan Antibiotik di RS

Kebijakan Khusus

Hasil lab tepat → Pemberian antibiotik tepat

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2. Tata Laksana KLB MDRO

Lab Mikro:
MDRO

Nilai
Kritis:
Telp/LIS

PPI:
Kewaspadaan
transmisi

CRAB, CRKP, CRPsA, VRE…..

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3. Prinsip Pengambilan spesimen mikrobiologi

• Keamanan: Kewaspadaan standar

• Pedoman Umum:
- sebelum pemberian antibiotik
- aseptik
- saat dan tempat yang tepat, volume cukup
- wadah berlabel identitas pasien dan jenis spesimen
- Lembar permintaan lengkap (identitas, DPJP, a.b)

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4. Tahapan Pemeriksaan Mikrobiologi

• Mikroskopis: diagnosis awal, pemilihan antimikroba

• Kultur/biakan
• Uji kepekaan antibiotik/antijamur

Setiap tahap
ada QC

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5. Konsultasi Klinik

• Kontaminasi?/Kolonisasi?: data klinis dan kualitas spesimen

• Saran pemilihan antimikroba: empirik bila sensitivitas >80%

Contoh:
- pengambilan specimen?
- Bila MRSA apa antibiotiknya?
- Bagaimana kewaspadaan
transmisinya?

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6. Pelaporan Pola Mikroba kepekaannya
secara periodik

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6. Pelaporan Pola Mikroba kepekaannya
secara periodik

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Kontribusi PDS PatKLIn

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Struktur Organisasi PPRA

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 Antimicrobial Management Tools
Non-culture results (e.g.
Renal function antigen, NAAT, serology)
Hepatic function Non-micro lab Culture results
Micro lab data
Inflammatory markers data Pathogen MICs
(WBC, CRP, PCT)

Local
Medical Record microbiology
epidemiological
data
Drug allergies INFORMATICS Data by body site, hospital
Travel/exposure history
location, etc.
Immune status, co-morbidities

Anti- Guidelines
Pharmacy (local, regional,
Records microbial national,
Decisions international)

Current & previous Abx Pneumonia guidelines

Possible drug interactions Sepsis guidelines
Possible Abx toxicities CDI guidelines

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 Contoh Restriksi dan Preotorisasi Antimikroba

Kategori I Kategori II Kategori III

Aminopenisilin Cepalosporin generasi 3 dan 4 Vancomisin
Penisillin Cepalosporin Antipseudomonas Teicoplanin
Cepalosporin (Gen.1 dan 2) Fluorokuinolon Antipseudomonas Linezolid
Khlorampenikol Flukonazol Tigecycline
Asam Fusidat Fosfomycin Carbapenem
Linkosamid Acyclovir Aminoglykosida
Makrolida Pirimetamin Fluorokuinolon (Gen.4)
Metronidazole Piptazo
Fluorokuinolon (Gen.1 dan 2) Colistin
Tetrasiklin Variconazole
Trimetoprim-sulfametoksasol Mycafungin
Nitrofurantoin Anidulafungin
Albendazole Gancyclovir
Mupirosin
Sulfadiazin

• Kategori I: tidak membutuhkan persetujuan Tim PPRA untuk diberikan.

• Kategori II: Boleh diresepkan atas indikasi spesifik, kemudian ditinjau oleh Tim PPRA dlm 3 hari kerja (72 jam)
• Kategori III: Membutuhkan persetujuan Tim PPRA sebelum diberikan, menggunakan Formulir Penggunaan
Antimikroba 72 jam.

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TAHAPAN PERAN DSPK DALAM PPRA

Parwati, 201841

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terimakasih

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