4/17/2013 1 Education : Dokter Umum, FK Universitas Sam Ratulangi 1987 Dokter Spesialis Penyakit Dalam FK Universitas Airlangga 1999 Konsultan Intensive Care FK Universitas Indonesia 2004 Position : Staff pengajar Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Tarumanegara Jakarta Kepala ICU RS Royal Taruma Jakarta Kepala ICU RS MH Thamrin Salemba Jakarta Organization : PERDICI PKGDI dr. Frans Pangalila, SpPD-KIC Tempat/tanggallahir : Surabaya, 31 Maret The Potential Use of Fosfomycine for Management of Multidrug-Resistant in ICU Frans JV Pangalila (Intensivist) Case Report : 31 years old - male with chronic steroid used due to lupus admitted to ICU : restlessness - red frothy sputum Chest X ray : bilateral infiltrate + cardiomegali Assessment - Lupus nephritis - Bronchopneumonia / Lung edema - Hyperglycemia - Severe sepsis
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Frans Pangalila - · PDF fileFrans JV Pangalila (Intensivist) Case Report : 31 years old - male with chronic steroid used due to lupus ... Assessment : Chronic Subdural Hematom + Stroke
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4/17/2013
1
Education : Dokter Umum, FK Universitas Sam Ratulangi 1987
Dokter Spesialis Penyakit Dalam FK Universitas Airlangga
1999
Konsultan Intensive Care FK Universitas Indonesia 2004
Position : Staff pengajar Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Tarumanegara Jakarta
Kepala ICU RS Royal Taruma JakartaKepala ICU RS MH Thamrin Salemba Jakarta
Organization : PERDICIPKGDI
dr. Frans Pangalila, SpPD-KICTempat/tanggal lahir : Surabaya, 31 Maret
The Potential Use of Fosfomycine for Management of Multidrug-Resistant in ICU
Frans JV Pangalila(Intensivist)
Case Report :31 years old - male with chronic steroid used due to lupusadmitted to ICU : restlessness - red frothy sputum
Chest X ray : bilateral infiltrate+ cardiomegali
Assessment- Lupus nephritis- Bronchopneumonia / Lung edema- Hyperglycemia- Severe sepsis
....day 5 in HCU ( day 1 in ICU )developed : papule-vesicle started from the neck-facies and then entirely the whole bodyhemodynamic become unstable and hematemesis melena (+)
Chest x ray : infiltrate >>> + cardiomegali
Clinical Assesment Day 5 in ICU
Acute Respiratory Distress Syndrome (ARDS)-PaO2 / FiO2 ratio 125
Do You Know - What has been reported by Global Sepsis Alliance ( GSA)??
“ Every seconds someone dies of Sepsisacross the globe “
The Bacterial ChallengesECDC/EMEA joint technical report september 2009
each year, about 25.000 patients die in the EU from an infectioncaused by multidrug-resistant bacteriainfections due to these selected multidrug-resistant bacteria in the EU result in extra healthcare costs of > 900 million EUR andproductivity losses of at least EUR 1.5 billion each year
Appropriate :- the use of an antibiotic→ the etiologic of microorganism is sensitive andin a correct time
Adequate :- the correct dose for the
correct duration withadvantageous pk/pd parameter at the site of infection
- combination if possible
Appropriate- sensitivity and timing
Adequate - penetration
Best Outcome
Optimal(pk/pd driven)
We always required“ Early Appropriate-Adequate Antimicrobial Treatment “
The common reason of inappropriate Antimicrobial that trigger the MDR infection
lack of confidence to diagnose an infection and to identified highrisk of MDRpoor understanding of pk/pd parameterlack knowledge of local resistance antibiogram data
Population of patients not infected with MDR Infection
Axiom : its really important for the physician to appreciate - what they entertained for the first time !!....sepsis – septic shock ?
not Critically Ill patients
Critically Ill patients
Baddour et al.AJRCCM 2004
Combination antibiotic therapy improved survival among critically ill patiens with bacteremic pneumococcal (but limit the duration of the combination to 3 - 5 days)
Pathogens associated with inappropriate initial therapy in VAP
Axiom : its important for the physician to identified an High Risk of MDR for the first time !!
Clinical and Economic Implications of an Extended -Infusion Dosing Strategy of Piperacillin-Tazobactam
for P.aeruginosaat Albany Medical Centre, investigators devised an alternative Pip-Tazodosing scheme that optimized pharmacodynamic (50% T > MIC) at atotal daily dose less than traditional dosing methodsidentified : P/T 3.375 g every 8 hours (4-h infusion) as an alternativemeans to traditional P/T dosing 3.375 g iv q4-6h (0.5 –hour infusion)
Lodise TP et al CID 2007
Known your local data
Local Data : sensitivity and antibiogram Royal Taruma Hospital
The recent case : Mr J 68 yrs (13 april 2012)Assessment : Chronic Subdural Hematom + Stroke NH + COPD+ NIDDM, after 3 weeks in ICU with tracheostomy - Culture : A.baumanii (+) Problem : difficult weaning !
What is the Appropriate AntimicrobialChemotherapy should be given to this case ??
• 8 patients with HAP• MIC to doripenem 4 - 8 ụ/ml• clinical cure 60% microbial cure 72%,respectively• with doripenem 1g 4 hour infusion target attaintmentfor P.aeruginosa with MIC = 4ụ/ml , 97.2%
Clinical Characteristic and Outcomes of 18 patients with Carbapenem-Resistant P.aeruginosa and A.baumanii VAP
Treated with Combination Carbapenem-FosfomycineInternal File Data : ICU Royal Taruma Hospital
• 18 patients with Ventilator Associated Pneumonia after at least 10 - 12 days hospitalized ( consist of 15 patientsPseudomonas (83%) and 3 patients Acinetobacter (17%)
• Treatment arm : meropenem 3 x 1 gr or doripenem 3x1gr(4 hour infusion) with fosfomycine 3 x 2gr (1.5 - 2 hourinfusion)
• Time to receipt of combination regimen : 5 - 6 days• Results :
- P.aeruginosa : clinical improvement 73.3%- A.baumanii : all failure ( 2 patients death and 1 patien change toanother antibiotic )
Known your local dataLocal Data : ESBL 2012 ( Royal Taruma Hospital )
Internal Data File : ICU Royal Taruma Hospital
Key Issues
Early appropriate-adequate antimicrobial therapy ( within1 hour after diagnosis ) should be administration in severe infection (combination if possible) Host characteristic, source of infection and local ecologyare determinants of choice empirical antimicrobial therapyUse of pk/pd principles to optimize dosing in order tominimize risk of failure and emerge of bacterial resistanteven with limited data : Fosfomycine could be provide asalternative combination antimicrobial in severe infectiondue to MDR pathogen