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

Surveilans of AMR (MDRO) in Indonesia

Kuntaman FK Universitas Airlangga/RSU Dr. Soetomo Surabaya

Komite Pengendalian Resistensi Antimikroba

Kementerian Kesehatan Republik Indonesia

kuntaman@fk.unair.ac.id, 08113410352

Pelatihan PPRA & SNARS, Surabaya, Jan,19-21, 2018

Problem Statement

• Surveillance: is the monitoring of the behavior, activities, or other changing information, usually of people for the purpose of influencing, managing, directing, or protecting them (Health Services)

• Focus AMR &/or AMU

• Indicator: ?? (should be determined): National

– Evidence based

– Sensitive to be monitored

– Higher impact in clinical setting Inf Dis

The Surveillance Steps

• Commitment

• Situation analysis

• Governance

• Mapping

• stakeholder involvement

• for developing/strengthening

the existing system (in every

ward/center)

IDSA Guidelines. Clin. Inf. Diseases Advance Access published July 10, 2013

The Surveillance Steps

• Funding and Priority

• Approach: Bottom-up & Top-down

• Effectivity and Efficiency

• Networking: Local, Regional, Global

• Minimal requirements of

participants/centers: Assessment

Global Antimicrobial

Resistance Surveillance

System

GLASS-2014

Bacterial Indicator AB

1. E coli SXT, QNs, C3rd,Carb,Col,AMX

2. K pneumoniae SXT, CIP, C3rd,Carb,Col,AMX

3. Acin baumannii AN, TGC, Carb, Col

4. Sta aureus FOX, MRSA?

5. Strep pneumo OXA, Pen, SXT, CRO/CTX

6. Salmonella spp QNs, C3rd, Carb

7. Shigella spp QNs,C3rd,Azithro

8. N gonorrhoeae FIX, CRO, Azithro

GLASS-2014

Specimen Bacteria

1. Blood E. coli; K. pneumoniae; A. Baumannii;

S. aureus

S. pneumoniae; Salmonella spp.

2. Urine E coli, K. pneu

3. Faeces Salm, Shigella

4. Urethra, Cx N go

Metric Measurement

Specimen Measurement = Indicator

1. Urine Num: Pathogen/s identified vs AST

Deno: Total Urine sample

Num: E coli & ESBL+

Deno: Total E coli

Num: E coli & Cip-Res

Deno: Total E coli

2. Blood Num: E coli in Spesis Pts

Deno: Total Population (per 100.000 Pop)

Indonesia Surveillance

on AMR/MDRO &/or AMU

(Antimicrobial Use)

MDRO: sangat banyak

• Surveillance:

–Semua: ??

–Indikator spesifik: ?? Apa: ??

–Murah & Manfaat ++

MDRO: Multiple Drug Resistant Organisms

• Resistance against minimally 3

Classes of Antibiotics

• Ex:

–Ceph, FQ, Amino

–FQ, TGC, MEM

–ERY, DA, TET

–SXT, ERY, GEN

ESBL: Extended Spectrum Beta Lactamase

• Mostly Gram neg Bacteria

• Resistance against:

–Ceph-3rd

–Aztreonam

–Cross: FQ

–Others: ??

• Data Indonesia: Sensitive: AK, FOS,

MEM, TGC, PTZ/SCF

Plan

• Active Surveillance:

–Active, targeted surveillance

–High cost

• Passive Surveillance:

– Low Cost Surveillance

– Based on Routine data on Health

Care Services

– Centers: Hospitals

WHAT:

- The routine Lab Examination, paid by

system (Insurance)

- Centers: Hospital-2, 3 & Facilities: ?

- Many centers, representative of Regional,

National (Indonesia)

- Beneficial for Health Services & National

Policy Handling of Inf Dis

Passive surveillance

Target Selection:

• Ward: Surgical vs Medical

• Disease & Specimen:

–Pneumonia Sputum

–UTI Urine

–SSI Pus

• Hospital:

• Time: 2018

• Pathogens: Rank

Target Resistant Bacterial :

• All bacterial pathogens

• Specific bacterial Resistance:

– ESBL Producing bacteria

– MRSA

– Carbapenem Resistant Pseudo

aeruginosa

• Now in Indonesia:

– ESBL: range about 45-82%

–MRSA: range about 30-50%

An Example

1. The Prevalence & Susceptibility pattern of ESBL Producing bacteria in Dr. Haz Hospital Malang 2017

2. The pattern of bacterial agents and its susceptibility among sputum isolates in Dr Hiz Hospital Mojokerto 2017

3. The prevalence and susceptibility pattern of MRSA and MSSA in Huv Hospital Magetan 2017

4. The ESBL producing bacterial agent from Sputum and Urinary specimen in Han Hospital Solo 2017

An Example

1. The Prevalence & Susceptibility pattern of ESBL Producing E coli and Kl pneumoniae in Dr. Haz Hospital Malang 2017

Why E coli & K pneumo: 80-90% ESBL

Prevalence in: (E coli or K pneu or both) • Sputum • Urine • Blood • Pus

Susceptibility ESBL-E coli or K pneumo or Both against: CTX, CRO, FEP, AMC, AK, PTZ, SCF, MEM,

20

Producing microbes Total %

Citrobacter freundi 1 0.5 Citrobacter koseri 1 0.5 Citro werkmanii 1 0.5 Ent aerogenes 1 0.5 Entero cloacae 12 6 E coli 91 44 Kleb oxytoca 2 1 Kleb pneumo 93 45 Proteus mir 1 0.5 Seratia fonficola 1 0.5 Seratia marcescens 1 0.5 Total 205 100

ESBL Multicentre Study Jan-June 2010 Surabaya, Semarang, Malang

21

All Isolates Jan 2010 until June 2010 ESBL Producers Surabaya, Semarang, Malang

E coli (n=91) Kleb pne (n=93)

Antibiotic Res (%) Res (%)

Cefotaxim 89 97,8 87 93,55

Meropenem 0 0 3 3,23

Fosfomycin 4 4,4 3 3,23

Cefo-Sulb 3 3,3 4 4,30

Amikacin 7 7,7 8 8,60

Ciprofloxacin 68 74,7 43 46,24

22

Isolates Jan 2010 until June 2010 Specimens: ESBL Producers SBY, MLG

E coli (%) Kleb pne (%)

Specimen Sby

(n=46) Malang (n=18)

Sby (n=44)

Malang (n=26)

Urine 46 39 22 19

Blood 8 11 13 8

Pus 13 33 29 35

Sputum 11 11 31 31

Faeces 20 6 0 4

Others 2 0 5 4

Summary

• Surveillance targeting on: AMR & MDRO

• Plan: Active vs Passive

• Passive Surveillance Low Cost: Cost paid by Health Care System

• Specify:

– Selected ward or whole hospital wards

– Specified specimen: Blood, Sputum, Pus ??

– Specified Time: Jan-July 2018

– Specify: Targeted Bacteria: ESBL, MRSA, Acinetobacter baumanii ??