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 hospitals 1,2  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 ICU 3  Efforts being taken nationally: AM resistance control program in hospitals 4 2

AB audit in ICU CMH Objectives  Primary: to determine the quality of AB usage according to Gyssens’ criteria 5  Secondary: to see antibiotic usage pattern and AM resistance pattern 3 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 timing II: 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 4 Gyssens’ category for quality of AB use 5

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 5

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) 6 Reasons for AB: Medical vs. surgical

7

8 Quality according to Gyssens Jan-Feb, 2010

9 Quality 2010 vs I IIIIIIVV Meropenem Ceftriaxone Ceftazidime

10 Nama_Antibiotik0IIIAIIBIICIIIAIIIBIVAIVBIVCIVDVVI Ceftriaxone Ceftazidime Cefoperazone Meropenem Metronidazole Cefotaxime Levofloxacin Coamoxiclav Amikacin Piptazo Ceftizoxime Vancomycin Sul-perazon Cefazolin Gentamicin Ampi-Sulbactam Chloramphenicol Cefepim Ciprofloxacin Azithromycin Aztreonam Quality according to Gyssens (Jan-Febr)

11 No. of microbial isolates (Jan-Feb) MikroorganismeNo. of isolate No growth9 Klebsiella pneumoniae4 Acinetobacter baumannii6 Escherichia coli3 Methicillin Resistant Staphylococcus aureus (MRSA)6 Methicillin Sensitive Staphylococcus aureus (MSSA)1 Enterobacter aerogenes1 Serratia odorifera1 Methicillin Resistant Staphylococcus epidermidis(MRSE)1 Proteus Mirabilis1 Pseudomonas aeruginosa6 Chryseomonas Luteola2 41

12 Antimicrobial resistance pattern (% sensitivity) No. Isolates Ceftriax.Ceftazid.Cefoper.Merop.Cefotax.Levoflox. Acinetobacter baumannii Pseudomonas aeruginosa MRSA*6NT Klebsiella pneumoniae Escherichia coli Chryseomonas Luteola 2NT 50NT50 MSSA1NT 100 Serratia odorifera1100 MRSE*3NT

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 13 Conclussion The 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 14 Policy implication