theimpotantofinfection prof. tony

7/28/2019 Theimpotantofinfection Prof. Tony

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Twelve Desirable Attributes for Computer-based Patient Records (Adapted from the

Institute of Medicine's Task Force on Computer-based Records)1

A CPR should:Contain problem lists

Support recording health status and functional level

State the logical basis for all diagnoses and conclusions

Be able to be linked to other clinical patient records

Address comprehensively patient information confidentiality

Be accessible in a timely manner by all who have authorized access

Allow selective retrieval and formatting of information by users

Be linked to local and remote knowledge, literature, and administrative databases

Provide decision analysis tools, clinical reminders, and prognostic risk assessment

Use a defined vocabulary and support structured data

Help providers and institutions manage and evaluate quality and costs

Be flexible and expandable to meet future needs



Content of presentation

• Introduction

• Global trends in antimicrobialresistance

• Infectious diseases• Other areas of concern

• Essential medicines and

antimicrobial resistance• Irrational use

• Access

• Quality



Content of presentation

• Regional situation• Status of antimicrobial resistance

(AMR)

• Assessment of economic impact• Policy options

• Recommendations



Introduction

• Antimicrobial resistance is both anatural phenomenon and a major global threat to public health

• Through replication and conjugationby “jumping” plasmids

• Observed soon after introduction of penicillin



Introduction• The link between antimicrobial

resistance development andinappropriate use of antimicrobials inhumans and animals is acknowledged

• Health Assembly resolution WHA51.17(1998)

• Regional Taskforce on AntimicrobialResistance (2000)

• WHO Global Strategy for Containment of Antimicrobial Resistance (2001)

• Regional Consultative Committee (2002)



Global trends:

Infectious diseases

• Acute respiratory infections

3.5 million killed globally (1998)• Influenza and pneumonia

• Diarrhoea

2.2 million killed globally (1998)

• E. coli , shigellosis, cholera

• Lack of testing for antibiotic sensitivity

during outbreaks

Infectious diseases still account for 45% of deaths in low-income countries



Global trends:

Infectious diseases

• HIV/AIDS• Resistance to multidrug therapy

• Malaria• Chloroquine no longer effective in 81

of 92 countries

• Tuberculosis• ? 20% of resistant new tuberculosis

cases are multidrug resistant

• Cost implications

Infectious diseases still account for 45% of deaths in low-income countries



Global trends:

Nosocomial

infections• Intensity of use of antimicrobials

in hospitals

• Increasing resistance of highlyvirulent strains (Staphylococcus aureus )

• Hospital acquired infections(mainly drug resistant microbes)account for significant death ratesand numbers• 40 000 deaths/year in USA



Global trends:

Food production• About half of all antibiotics

produced are used for farming

• Reports indicate that 50% of human antimicrobial resistanceis caused by growth promoters

in livestock• Where growth promoters are

phased out, antimicrobialresistance in livestock drops

dramatically



Medicines:

(ir)rational use

• 25% – 75% of antibioticprescriptions inappropriate

• Empirical treatment, lack of diagnostic

services

• Lack of targeted education

• 50% – 90% bought privately

from community pharmacy;

• half for 1-day treatment



Medicines:

Access

30

35

40

45

50

55

60

65

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

0

5

10

15

20

25

30

35

40

R&D expenditure

(US$ billions)New

products(number)

Multitude of problems:

Drug “pipeline”

Between 1975 and 1997

1223 new compounds launched only 11 for tropical diseases

M di i



Medicines:

Access


Drug “pipeline”

Focus on large markets



Medicines

Access


Drug “pipeline”

Focus on large markets

Geographical inequities

Financial inequities

More than 100 million people inthe Region do not have regular access to essential drugs;

Problem not only found in thelow income countries

EMRcountries

Lessthan 50%

50-80%

80-95%

More than95%

4 4 6 8

Percentage of population withregular access to essential drugs



Medicines:

Quality

not all countries havewell-functioning drugregulatory systems

10% –20% of drugs failquality testing

substandard andcounterfeit drugscontinue to kill

Quality and safety standards exist,enforcement varies greatly:



Medicines:

Quality

Incorrect

ingredient

16%

No active

ingredient

60%

Incorrect

amount

17%

not all countries havewell-functioning drugregulatory systems

10% –20% of drugs failquality testing

substandard andcounterfeit drugs

continue to kill

Quality and safety standards exist,enforcement varies greatly:

Other

7 %No Ingredient

59 %

Amount

17 %

Incorrect Ingredient

16 %



Regional trends:

Health implications

• Similarity in terms of scope and magnitudeof the problem

• Link between antimicrobial resistance andirrational use of medicines is establishedin various studies

• High levels of drug resistance are found

throughout the region for medicines usedin common infectious diseases• Tuberculosis, acute respiratory infections,

urinary tract infections, malaria, etc.



Regional trends:

Health implications• Multidrug resistance is commonly

found

• Need to “underpin” treatment choicewith laboratory tests

• Need for time-series to determine

trendsAntimicrobial resistanceis increasing in the

World

Wide availabilityof antimicrobials

Widespread useof new generationantimicrobials



Regional trends:

Economic implications

Cost of ARI, diarrhoea,tuberculosis and malaria

treatmentTotal morbidity

First line

Second line

Third line

Total cost of

treatment

First line

Second line

Third line

R i l t d



Regional trends:

Economic implications

Cost of tuberculosistreatment

TB morbidity

First line Second line Third line

Cost of TB treatment

First line

Second line

Third lineChine

India

Indonesia

P li & t t ti



Policy & strategy optionsAddressing antimicrobial resistance

requires a comprehensive multisectoral

approach

• Government (health

systems)• Patients and the

general community

• Prescribers and

dispensers• Hospitals

• Pharmaceutical

industry

• Food production

Advocacy and intersectoralaction

Regulations

Policies

Guidelines and formularies

Education Surveillance

Infection control

Diagnostic services

“Target audience” “Intervention area”

T di



Target audience:Government (health systems)

• Advocacy and intersectoral action• Intersectoral task force

• Resources to promote the implementation

of interventions• Indicators to monitor and evaluate the

impact of resistance

• Regulations• Prescription-only status

• International quality, safety and efficacy

standards



Target audience:Government (health systems)

• Policies and guidelines• National Drug Policy and Essential Drugs

List (EDL)

• Surveillance• Designate or develop reference

microbiology laboratory facilities

• Drug resistance surveillance



Target audience:Patients and the general

community

• Health education• Appropriate use of antimicrobials

• Disease prevention (immunization, vector

control)

• Hygiene

T t di



Target audience:Prescribers and dispensers

• Education (undergraduate anpostgraduate)• Appropriate use and containment

• Disease prevention and infection control• Diagnosis and management

• Management, guidelines andformularies

• Prescription audits / prescription limits• Standard treatment guidelines and prescription

limits

• Regulation• Professional registration based on continuing



Target audience:Hospitals

• Management• Infection control programmes

• Hospital therapeutic committees

• Monitor antimicrobial usage

• Diagnostic laboratories• Ensure access to microbiology laboratory

services• Diagnostic and treatment option support



Target audience:Pharmaceutical industry

• Promotional activities

• Control and monitor promotion for

medicines(WHO ethical criteria)

• Quality

• Good Manufacturing Practice (GMP)

of pharmaceuticals and diagnostics



Target audience:Food production

• Regulation• Prescription-only use of antimicrobials for

disease control

• Phase out use of antimicrobials for growthpromotion

• Monitor resistance

• Guidelines

• Develop guidelines for veterinarians toreduce overuse and misuse



Recommendations

To Member States

• National intersectoral task force onantimicrobial resistance

• Legislation and regulation:prescription-only use of antimicrobials

• Hospital therapeutics committeesand infection control programmes

• Essential drugs concept ineducational programmes

ecommen a ons



ecommen a onsTo WHO

• Continued advocacy with Member States

• Support for surveillance networks

• Support for operational research• Exploring the possibility of

designating regional regulatory

reference laboratories• Development of a regional strategy

on the prevention, control andmonitoring of antimicrobial drug

resistance



Some final points……….

• Antimicrobial resistance control is notan option, it is a must

• Health and economic incentive

• Implementation of comprehensive,integrated strategies involving all keypartners will:

• Lead to control of antimicrobial resistancedevelopment

• Improve the quality of health services;antimicrobial resistance control as a “proxyindicator” for an effective essential drugsprogramme



Prolonged fever is a temperature above normal for three weeks or more. It

may be continuous or swinging. It is not hyperthermia, which is an

uncontrolled rise in temperature due to thermal overload, as in heatstroke.

Many more causes exist than can be named here, but those likeliest in

general practice are listed.

GF Abscess UTI Carcinoma RA

Generalise

d

lymphaden

opathy?

Yes No No Possible No

Localised

painful

swelling?

No Possible No No Possible

Frequency

of

micturition

?

No No Yes No No

Rapid

weight

loss?

Possible Possible No Yes Possible

Joint

swelling? No No No Possible Yes



http://www.rockefeller.edu/vaf/cells70.htm



ARBO-VIRUS = Arthopode-borne virus

Penularan:

Gigitan artropoda: nyamuk, lalatextrinsic incubation period

Patokan Diagnosis Klinis



Patokan Diagnosis Klinis

1. Demam tinggi mendadak dan kontinyu 2-7 hari

Manifestasi perdarahan: RL; petekie, purpura,ekimosis, epistaksis, perdarahan gusi, hematemesis

dan melena

3. Renjatan hipovolemik: nadi cepat dan lemah,

tekanan nadi < 20mmHg

Laboratorium

1. Trombositopenia ( < 100,000 UI)

2. Hemokonsentrasi: hematokrit > 20 vol% dari masa

rekonvalesen

2. Nyeri Kepala, nyeri retro-bulbair, mialgia, ruam kulit,

manifestasi perdarahan, dan lekopenia

3. Tanda Perembesan Plasma

Derajat Penyakit DBD



Derajat Penyakit DBD

IDemam, gejala tidak

khas,

RL positif

IIDerajat I dengan

perdarahan spontan

III

Kegagalan sirkulasi: nadi cepat,

lembut, kecil,

tekanan nadi < 20 mmHg,Hipotensi,

kulit dingin, lembab, gelisah

IVRenjatan berat, nadi tidak

teraba, tekanan darah tidak

terukur

DD

DBD

DBD

DBD

Rawat Jalan

Observasi di Puskesmas/

RS tipe C/D

Rawat Inap Puskesmas/

RS tipe C/D

Rawat Inap

RS tipe C/B/A

Rawat Inap

RS tipe B/A

DBD

Demam, 1/> nyeri kepala

nyeri retro-bulbair,

mialgia, antralgia, ‘flush’

Gejala Tatalaksana



Tersangka DBD

Panas

Kedaruratan Tanpa Kedaruratan

RL +Trombosit < 150,000/ ul

Rawat Ya Tidak

Pulang

Pencegahan DBD

Pesan: KU

Kontrol

Lapor: Dinas Kesehatan

Lurah

PSN

Pre/syok, muntah

kontinyu, kesadaran

muntah-BAB darah,

kejang

Patogenesis Renjatan pada DBD



Patogenesis Renjatan pada DBD

Secondary Heterologous Dengue Infection

Virus Replication Anamnestic Antibody

ResponseVirus Antibody Complex01

Complement Activation

Anaphylatoxin(C

3aC

5a)

Complement

Histamine Level in24-hours urine

Vascular Permeability

Leakage of Plasma Ht

Na+

Fluid in theSerous Cavite

Hypovolemia

Shock

Acidosis Anoxia +

> 30 % in

Shock Cases

24 - 48 hrs



DBD Tanpa Syok (1) Cairan Awal



DBD Tanpa Syok (1) Cairan Awal

RL D5 7 ml/Kg BB/Jam

Monitor Tanda Vital/Kadar Ht, PP

PerbaikanHt turun

Nadi/TD stabil

Diuresis cukup(2) Tetesan dikurangi

5 cc/Kb BB/jm

3 cc/kg BB/jam

Perbaikan

Lanjutkan tetesan (2)

(4) IVFD stop 24 - 48 jam

Tanda vital/Ht stabil

Tidak ada PerbaikanHt Naik

PP turun

Nadi naik

Tek Nadi < 20 mg Hg

Diuresis kurangVital/Ht berubah

Perbaikan

(3) Tetesan Naik 10 mg/kgBB.jam15 cc/kgBB/jam

Vital labil

Ht Naik

distress

Koloid (5)

Ht turun

Transfusi darah

(6)Perbaikan ke (2)diuresis cukup

DBD k



DBD syok

RL 20 cc/kgBB/jam, O2: 2-6 l/m

1/2 jam

Belum teratasiTeratasi

RL: 10 cc/kgBB/jam

Ht Naik

Koloid

Dextran 40Plasma (10 cc/kgBB/jam

Dopamin 10 tetes/menit(8 mg/kgBB/mennit)

Ht turun

Transfusi darahJumlah Cairan

seperti tanpa syok

.

1/2 jam



“poverty”

Low diet

quality

death

theimpotantofinfection prof. tony

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