do and don’ts in antibiotics-dr. tonny
DESCRIPTION
BAHAN KULIAH SEMINAR RS. PONDOK INDAH 30 NOV 2011PENANGANAN INFEKSI TERKINITRANSCRIPT
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Do and don’ts in antibioticsDo and don ts in antibiotics
Tonny Loho
Div Infeksi Dep Patologi KlinikDiv Infeksi Dep Patologi Klinik
FKUI – RSCM
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AntibiotikAntibiotik
• Do – kapan AB boleh diberikan ?Do kapan AB boleh diberikan ?• Bila ada tanda2 infeksi bakteri• ‐ tanda radang – tumor• ‐ tanda radang – tumor
rubork lkalordolor functio laesa
DD/ inflamasi – gout
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AntibiotikAntibiotik
• Demam DD/ infeksi virus, drug fever / , gLaboratorium• hitung leukosit – meningkat atau menurun
* neutrofilia* shift to the left – batang meningkat* IT ratio – batang/batang+segmen – 0,1
• Kelainan morfologi leukosit – hipersegmentasi, granulasi toksis vakuolisasi Dohle bodiesgranulasi toksis, vakuolisasi, Dohle bodies
• CRP – C reactive protein • PCT – procalcitoninPCT procalcitonin
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Antibiotik – don’tAntibiotik don t
• Inflamasi – bukan infeksi – arthritisInflamasi bukan infeksi arthritis
• Alergi
i f• Virus – Dengue fever, DHF
Varicella
• Flora normal –
* Streptococcus viridans – sputum Streptococcus viridans sputum
* Escherichia coli non patogen – feses
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Antibiotik – don’tAntibiotik don t
• Kontaminasi ‐ pengambilan urinKontaminasi pengambilan urin
• biakan urin :
• Jumlah kuman < 1000/mL urin• Jumlah kuman < 1000/mL urin
• 1000 ‐ < 10.000/mL
• 10.000 ‐ < 100.000/mL
• Kecuali > 100.000/mL urin – 1 atau 2 kuman ISK
• > 100.000/mL urin – 3 kuman > 100.000/mL –kontaminasi
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Antibiotik – don’tAntibiotik don t
Kontaminasi :o ta as :• Biakan sputum : pewarnaan Gram sputum –sputum layak dibiak/tidakp y
• Leukosit > 25 /lpk• Epitel < 10 /lpkp / p• Leukosit – infeksi di paru
* geriatrig* HIV/AIDS
• Epitel – kontaminasi ludahEpitel kontaminasi ludah
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Antibiotik – don’tAntibiotik don t
KontaminasiKontaminasi
• Biakan darah
• Staphylococcus epidermidis• Staphylococcus epidermidis –
• Kontaminasi atau Penyebab ?
• 2 biakan darah –
* 2 tempat pungsi vena yg berbeda
* waktu hampir bersamaan
• Interpretasi – selalu kaitkan dengan gejala klinikp g g j
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Antibiotik – don’tAntibiotik don t
• Bukan kuman patogen di tempat tsbBukan kuman patogen di tempat tsb
• Feses – non patogen
l b i ll i‐ Klebsiella pneumoniae
‐ Enterococcus faecalis
‐ Pseudomonas aeruginosa
‐ Proteus mirabilisProteus mirabilis
‐ Acinetobacter sp
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Patogen di GI tractPatogen di GI tract
• Kuman patogen di traktus gastro intestinal :Kuman patogen di traktus gastro intestinal :
• E. coli – enterotoxigenic
h ienteropathogenic
enterohemorrhagic
enteroinvasive
enteroaggregativeenteroaggregative
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Patogen di GI tractPatogen di GI tract
Kuman patogen di traktus gastro intestinal :u a patoge d t a tus gast o test a :• Salmonella enteritidis ser Typhi• Paratyphi A, B, CParatyphi A, B, C• Shigella dysentriae, Shigella sonnei, Shigellaflexnerif
• Yersinia enterocolitica• Vibrio cholerae• Campylobacter jejuni• Helicobacter pyloriHelicobacter pylori
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Patogen di GI tractPatogen di GI tract
Kuman patogen di traktus gastrointestinal :Kuman patogen di traktus gastrointestinal :• Aeromonas hydrophyla• Plesiomonas shigelloides• Plesiomonas shigelloidesParasit penyebab diare :E t b h t l ti• Entamoeba hystolytica
• Entamoeba coli • Balantidium coli • Giardia lamblia
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Patogen di GI tractPatogen di GI tract
Virus penyebab diare :Virus penyebab diare :• Rotavirus• Adenovirus• Adenovirus • Norwalk virus J b b di C did lbiJamur penyebab diare : Candida albicansPenyebab diare yang lain :• Food poisoning • maldigesti
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Patogen di GI tractPatogen di GI tract
Food poisoning :Food poisoning :
• Staphylococcus aureus
ill• Bacillus cereus
• Listeria monocytogenes
• Salmonella enteritidis
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Antibiotik – don’tAntibiotik don t
• Bila kadar pada tempat infeksi tidak mencapaiBila kadar pada tempat infeksi tidak mencapai MIC – Minimal Inhibitory Concentration
• Tidak diberikan pada infeksi saluran kemih :• Tidak diberikan pada infeksi saluran kemih :
‐ Chloramphenicol,
‐ Cefoperazone
‐ Cefoperazone sulbactam p
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AntibiotikAntibiotik
Antimikroba yang khusus infeksi saluran kemihAntimikroba yang khusus infeksi saluran kemih
• Nitrofurantoin
lidi i id• Nalidixic acid
• Pipemidic acid
• Norfloxacin
• TrimethoprimTrimethoprim
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Antibiotik ‐ Don’tAntibiotik Don t
Tidak boleh diberikan pada meningitis :da bo e d be a pada e g t s :• Quinolone,• aminoglicosides,aminoglicosides, • Tetracycline• Cephalosporin generasi 1 – cephradineCephalosporin generasi 1 cephradine• Cephalosporin generasi 2, kecuali cefuroximeparenteralp
• Macrolide – erythromycin• ClindamycinClindamycin
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Antibiotik – don’tsAntibiotik don ts
• Tidak boleh diberikan – bila efek samping amatda bo e d be a b a e e sa p g a atberat
• Quinolone – tidak boleh diberikan padap* wanita hamil – 2 minggu
pertama kehamilanp* ibu menyusui* bayiy* anak
• Kelainan kongenital, merusak epiphysis tulangKelainan kongenital, merusak epiphysis tulang
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Antibiotik – don’tAntibiotik don t
• Tidak boleh diberikan bila alergi pd AB tsbTidak boleh diberikan bila alergi pd AB tsb
• Tidak boleh diberikan bila ada pilihan lain yang kurang toksikyang kurang toksik
• Aminoglycosides – gentamicin, amikacin
* Nefrotoksis
* Ototoksis
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Antibiotik – don’tsAntibiotik don ts
• Tidak boleh diberikan bila kuman intrinsikTidak boleh diberikan bila kuman intrinsik resisten
• Salmonella Typhi :• Salmonella Typhi :
‐ resisten thd cephalosporin generasi 1 dan 2
‐ resisten thd aminoglycosides
• Streptococcus :p
‐ resisten thd aminoglycosides
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MRSA, MRSEMRSA, MRSE
• MRSA – methicillin resistant Staphylococcus S et c es sta t Stap y ococcusaureus
• MRSE – methicillin resistant StahylococcusMRSE methicillin resistant Stahylococcusepidermidis
• Resisten thd semua gol Beta laktamResisten thd semua gol. Beta laktam• Penicillin, cephalosporin gen 1,2,3,4, aztreonam, carbapenemp
• Sensitif – Vancomycin, teicoplanin, linezolid, tigecyclinetigecycline
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ESBLESBL
• ESBL – Extended Spectrum of Beta LactamaseESBL Extended Spectrum of Beta Lactamase producing bacteria
• Klebsiella pneumoniae Klebsiella oxytoca• Klebsiella pneumoniae, Klebsiella oxytoca Escherichia coli, Proteus mirabilis
R i hd l B l k li• Resisten thd semua gol. Beta lactam kecuali carbapenem
• Piperacillin tazobactam ?
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Antibiotik – don’tAntibiotik don t
Hindari penggunaanp gg• carbapenem atau• cephalosporin generasi 3 • untuk membunuh kuman Gram positif‐ Staphylococcus sp. ‐ Streptococcus sp. – kecuali meningitis – harus in vitro dgn MIC
• Walaupun pada tes kepekaan antimikroba in vitro• Walaupun pada tes kepekaan antimikroba in vitro –sensitif
• Bila masih ada pilihan lain – amoxicillin clavulanic acidp
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Antibiotik – don’tAntibiotik don t
• Hindari penggunaan ceftazidime untukHindari penggunaan ceftazidime untuk membunuh kuman Gram negatif ‐EnterobacteriaceaeEnterobacteriaceae
• Ceftazidime dicadangkan untuk :
P d‐ Pseudomonas sp.
‐ Burkholderia malei
‐ Burkholderia pseudomalei
‐ Acinetobacter spAcinetobacter sp.
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Antibiotik – don’tAntibiotik don t
• Hindari penggunaan carbapenemHindari penggunaan carbapenem
‐ sebagai first line therapy
li i• Kecuali – sepsis
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