Zunilda Djanun*, Rudyanto S**, Yulia Rosa***, *Dept. Clinical Pharmacology FMUI/CMH, **ICU CMH, *** Dept. Clinical Microbiology FMUI.

Zunilda Djanun*, Rudyanto S**, Yulia Rosa***, *Dept. Clinical Pharmacology FMUI/CMH, **ICU CMH, *** Dept. Clinical Microbiology FMUI

Introduction Antibiotics is the most frequently misused drug: in the

community and hospitals1,2

Inapproriate use of AB is the most influencing factor in the emergence of antimicrobial resistance

High antibiotics consumption is associated with high prevalence of nosocomial infections in ICU

Nonadherence to empirical AB guidelines is associated with increased in-hospital mortality in ICU3

Efforts being taken nationally: AM resistance control program in hospitals4

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AB audit in ICU CMHObjectives Primary: to determine the quality of AB usage according to

Gyssens’ criteria5

Secondary: to see antibiotic usage pattern and AM resistance pattern

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Methods Prospective: January-February 2010 Observation & patient’s chart AB usage:

Indications: prophylaxis, empiric, definitive, not known Choice of AB Dosages, duration, time and route of administration

0: Appropriate use of AM therapy/prophylaxis I: AM prescription is inappropriate due to improper timingII: AM prescription is inappropriate due to

Improper dosage (A), dosage interval (B), route (C)III: AM prescription is inappropriate due to

Excessive length of use (A) or duration to short (B)IV: AM prescription is inappropriate due to availability of

More effective alternative (A) Less toxic alternative (B) Less expensive alternative (C) Narrower spectrum alternative (D)

V: AM prescription is unjustified VI: information insufficient for categorization

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Gyssens’ category for quality of AB use5

Indication of AB

Prophylaxis: for appropriate case and given within 60 minutes before incision

Empiric: given before ICU or in ICU for suspected infection

Definitive: given according to microbiological result (streamlining)

Not known (NK): Given without any suspected infection Given preoperatively for improper case Given postoperatively but different from the prophylaxis Given in the ICU without any AB prior to surgery

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Results 165 patients: 134 surgical & 31 medical 5 out of 134 are not received AB 26 AB - J01 (OAT & antifungal are excluded) 254 usages with 1-12 days duration (surgical) 1-14 days duration (medical)

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Reasons for AB:Medical vs. surgical

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Quality according to GyssensJan-Feb, 2010

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Quality 2010 vs. 2009

2010 2010 20102009 2009 2009 2009 20092010 2010

I II III IV V

Meropenem

Meropenem

Ceftriaxone

Ceftazidime

Ceftazidime

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Nama_Antibiotik 0 I IIA IIB IIC IIIA IIIB IVA IVB IVC IVD V VI

Ceftriaxone 16 2 6 2 0 29 4 3 0 1 4 14 2

Ceftazidime 1 0 9 4 0 9 4 4 0 14 9 14 0

Cefoperazone 1 0 5 1 0 2 0 1 0 4 1 4 1

Meropenem 13 0 2 0 0 0 3 0 0 0 0 0 1

Metronidazole 3 1 2 2 0 0 0 0 0 0 0 4 2

Cefotaxime 1 0 2 1 0 1 2 2 0 0 0 3 0

Levofloxacin 4 0 4 0 0 0 1 0 0 0 0 0 2

Coamoxiclav 0 0 0 0 0 1 0 2 0 0 0 1 2

Amikacin 1 0 1 2 0 0 2 0 0 0 0 0 0

Piptazo 2 1 1 0 0 0 0 0 0 0 0 0 2

Ceftizoxime 0 0 0 0 0 0 0 0 0 3 0 1 0

Vancomycin 0 0 0 0 0 1 2 1 0 0 0 0 0

Sul-perazon 0 0 0 0 0 1 1 0 0 0 1 0 1

Cefazolin 1 0 0 0 0 0 0 0 0 0 0 1 0

Gentamicin 0 0 0 0 0 0 1 0 0 0 0 1 0

Ampi-Sulbactam 1 0 0 0 0 0 1 0 0 0 0 0 0

Chloramphenicol 0 0 0 0 0 0 0 1 0 0 0 0 1

Cefepim 0 0 1 1 0 0 0 0 0 0 0 0 0

Ciprofloxacin 0 0 0 0 0 0 0 0 0 0 0 1 1

Azithromycin 0 0 1 0 0 0 0 0 0 0 0 0 0

Aztreonam 0 0 0 0 0 0 0 1 0 0 0 0 0

Quality according to Gyssens (Jan-Febr)

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Sputum, 24

Blood, 5

Pus, 4

Urine, 2

No. of microbial isolates (Jan-Feb)

Mikroorganisme No. of isolateNo growth 9Klebsiella pneumoniae 4Acinetobacter baumannii 6Escherichia coli 3Methicillin Resistant Staphylococcus aureus (MRSA) 6Methicillin Sensitive Staphylococcus aureus (MSSA) 1Enterobacter aerogenes 1Serratia odorifera 1Methicillin Resistant Staphylococcus epidermidis(MRSE) 1Proteus Mirabilis 1Pseudomonas aeruginosa 6Chryseomonas Luteola 2

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Antimicrobial resistance pattern

(% sensitivity) No. Isolates Ceftriax. Ceftazid. Cefoper. Merop. Cefotax. Levoflox.

Acinetobacter baumannii 6 16.7 16.7

Pseudomonas aeruginosa 6 16.7 16.7 16.7 50 33.3

MRSA* 6 NT NT NT NT NT

Klebsiella pneumoniae 4 25 50

Escherichia coli 4 25 100

Chryseomonas Luteola 2 NT NT NT 50 NT 50

MSSA 1 NT NT NT NT NT 100

Serratia odorifera 1 100

MRSE* 3 NT NT NT NT NT

Summary Judging quality of AM prescribing using Gyssens

criteria is a complicated and time consuming work It should include an infectious disease physician and

use of STG Weakness: data only from ICU judgement on

duration may be biased Improvement: - reduced use of meropenem

- shorter prophylaxis

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ConclussionThe quality of AM use in ICU CMH was improved probably due to feedback and interventions that have been made

Microbial specimen should be collected prior to initiation of an AM therapy in ICU

AM therapy is reviewed in the morning parade List of AM with dosage recommendation is made available at

bed side Screening for MRSA is routine measures for patients with AM

therapy before admission AM audit results should be discussed with the surgery

department AM audit will include the quantity and economic analysis

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Policy implication