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

2. 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

3. 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

4. 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

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

6. 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. 7

8. 8 Quality according to Gyssens Jan-Feb, 2010

9. 9 Quality 2010 vs. 2009 2010 2009 2010 I IIIIIIVV Meropenem Ceftriaxone Ceftazidime

10. 10 Nama_Antibiotik0IIIAIIBIICIIIAIIIBIVAIVBIVCIVDVVI Ceftriaxone1626202943014142 Ceftazidime109409440149 0 Cefoperazone1051020104141 Meropenem13020003000001 Metronidazole3122000000042 Cefotaxime1021012200030 Levofloxacin4040001000002 Coamoxiclav0000010200012 Amikacin1012002000000 Piptazo2110000000002 Ceftizoxime0000000003010 Vancomycin0000012100000 Sul-perazon0000011000101 Cefazolin1000000000010 Gentamicin0000001000010 Ampi-Sulbactam1000001000000 Chloramphenicol0000000100001 Cefepim0011000000000 Ciprofloxacin0000000000011 Azithromycin0010000000000 Aztreonam0000000100000 Quality according to Gyssens (Jan-Febr)

11. 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. 12 Antimicrobial resistance pattern (% sensitivity) No. Isolates Ceftriax.Ceftazid.Cefoper.Merop.Cefotax.Levoflox. Acinetobacter baumannii 616.7 Pseudomonas aeruginosa 616.7 5033.3 MRSA*6NT Klebsiella pneumoniae 42550 Escherichia coli425100 Chryseomonas Luteola 2NT 50NT50 MSSA1NT 100 Serratia odorifera1100 MRSE*3NT

13. 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

14.  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