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LOGO Peran Uji Mikrobiologi & sensitivitas test MMDEAHHapsari UKK –IPT- IDAI.

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Presentasi berjudul: "LOGO Peran Uji Mikrobiologi & sensitivitas test MMDEAHHapsari UKK –IPT- IDAI."— Transcript presentasi:

1 LOGO Peran Uji Mikrobiologi & sensitivitas test MMDEAHHapsari UKK –IPT- IDAI

2 Kuntaman,Loknas PPRA

3 Mikroba dan manusia Sedikit mikroba yang patogen Banyak mikroba yang potensial untuk patogen Sebagian besar mikroba tidak patogen

4 FAKTOR BIOLOGIS Flora normal (mayoritas bakteri) pada kulit dan saluran pencernaan mencegah kolonisasi bakteri patogenik dengan mengeluarkan substansi toksik atau dengan bersaing mendapatkan nutrien. Ada 1013 sel dan terdapat 1014 bakteri, yang mayoritas hidup di usus besar.  Ada mikroba per cm2 di kulit (Staphylococcus aureus, Staphylococcus epidermidis, Diphtheroid, Streptococci, Candida dll.).  Berbagai macam bakteri hidup di hidung dan mulut  Di lambung dan usus halus terdapat Lactobacilli  Di usus halus terdapat 104 bakteri per gram dan di usus besar 1011 per gram, 95-99% di antaranya adalah anaerob.  Di saluran kemih terdapat koloni berbagai bakteri dan difteroid.  Setelah pubertas, terdapat koloni Lactobacillus aerophilus yang meng- fermentasi glikogen untuk mempertahankan pH asam. Flora normal menciptakan kesesuaian ekologis dalam tubuh, dan menghasilkan baktoriosidin, defensin, protein kationik dan laktoferin yang merusak bakteri lain.

5 Kuman patogen didapat dari kultur Gejala Klinis Kondisi pasien mis. septicaemia, endocarditis, osteomyelitis meningitis, UTI, pneumonia pharyngitis Bagaimana mengetahui patogen tertentu dapat menyebabkan penyakit tertentu? Diagnosis dan terapi infeksi tidak tergantung dari kuman tetapi juga melihat hasil laboratorium yang lain serta gejala klinis pasien

6 Alur Pemeriksaan Mikrobiologi

7 Contents Handling specimen 1 Diagnosis Laboratorium Infeksi 2 Peta medan kuman 3 Pemilihan AB berdasarkan sensitivitas test Mekmnisme Resistensi

8 Diagnosis of Bacterial Infection Patient Clinical diagnosis Haematology Biochemistry Non-microbiological investigations Radiology Sample Take the correct specimen Take the specimen correctly Label & package the specimen up correctly Appropriate transport & storage of specimen

9 The specimen must be collected with a minimum of contamination as close to site of infection as possible

10 Blood Culture  Two sets of blood cultures should be drawn. Number of sets positive correlates with true sepsis (except for coagulase negative Staph?) (Clin Microbiol. Rev 19: , 2006)  Catheter drawn blood cultures  Catheter drawn blood cultures are equally likely to be truly positive (associated with sepsis), but more likely to be colonized (J Clin Microbiol 38:3393, 2001.) One drawn through catheter and other though vein PPV 0f 96% Both drawn from catheter PPV 0f 50% Both drawn through vein PPV of 98%  Study of positive coagulase negative Staphylococcus cultures and sepsis (Clin Infect Dis. 39:333, 2004.)

11 A specimen must be collected at the optimal time(s) in order to recover the pathogen(s) of interest

12 A specimen must be collected at the optimal time(s) in order to recover the pathogen(s) of interest (cont)

13 A sufficient quantity of the specimen must be obtained to perform the requested tests

14 Blood Cultures  Volume of blood drawn is the single most important factor influencing sensitivity. A single set for an adult blood culture consists of one aerobic and one anaerobic bottle. Optimally 10 mL of blood should be inoculated into each bottle. Volume of blood for a pediatric culture can be related to the infants weight  Solitary blood cultures should be less than 5% (Arch Pathol Lab Med : )  If only enough blood can be drawn for one bottle, inoculate the aerobic bottle.  644 positive blood cultures, 59.8% from both bottles, 29.8% from aerobic bottle only and 10.4% from anaerobic bottle only (J Infect Chemother 9:227, 2003).

15 Pediatric Blood Cultures - Volume

16 Collect all microbiology test samples prior to the institution of antibiotics

17 Blood Cultures - Volume The magnitude of bacteremia may be low (<1cfu/ml) Higher volumes have higher yield

18 Urine - General  Collection method must avoid contamination  Clean catch, midstream voided  Catheterized urine  Suprapubic aspiration  Cultures performed quantitatively  Less than 10,000 per ml suggest contamination

19 Pengambilan spesimen yang benar  Urin – mid-stream  Hindari kontaminasi dengan flora perineal  LCS  Cegah kontaminasi  Cegah perdarahan  Kultur darah  Cegah kontaminasi dengan kuman di permukaan kulit Pengiriman spesimen ke laboratorium  Keterlambatan pengiriman akan menyebabkan keterlambatan diagnosis dan terapi  Pathogen mati  Pertumbuhan kontaminan  Kultur darah harus segera masuk inkubator  Bukan almari es ( refrigerator)  LCS segera dikirim ke Lab

20 Faktor –faktor yang berpengaruh atas hasil kultur darah  Sampel yang slalah  Sputum – didapat saliva  Terlambat kirim  LCS  Pertumbuhan kontaminan  Misal kultur darah  Pasien sudah mendapatkan antibiotika

21 Handling specimen Pus Darah Urin Tinja Sputum Turn Around Time Lab Mikrobiologi

22 Cara pengambilan, penyimpanan dan pengiriman bahan Petunjuk Umum  Pemeriksaan diambil sebelum diberikan antibiotik  Bahasn pemeriksaan diambil saat & lokasi yang tepat( untuk dapat kuman)  Tindakan aseptik  Jumlah cukup  Formulir diisi lengkap(riwayat penyakit, pengobatan,diagnosis  Pelabelan yang jelas Petunjuk Khusus  Air seni –penampungan pagi hari-steril- midstream/ kateter- segera kirim.( Urin diambil < 3 hari MRS)  Darah : diambil sesuai perjalan penyakit  Dengan media “bactec”  Ukuran sesuai dengan aturan

23 Lanjt..... Tinja  Pengambilan pada pagi hari atau tinja yang baru  Hapusan rektum kurang dianjurkan  Jumlah 10 gramn  Segera kirim LCS  Pengambilan dengan pungsi  Pengiriman segera mungkin

24 Culture diagnostic of typhoid weeks % patients with pos culture urine stool bloods

25 Contents Handling specimen 1 Diagnosis Laboratorium Infeksi 2 Peta medan kuman 3 Pemilihan AB berdasarkan sensitivitas test Mekanisme Resistensi

26 Laboratorium Mikrobiologi

27 Pemeriksaan Kultur Darah

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30 Contents Handling specimen 1 Diagnosis Laboratorium Infeksi 2 Peta medan kuman 3 Pemilihan AB berdasarkan sensitivitas test Mekanisme Resistens

31 Hasil Peta Kuman – sensitivitas PICU-NICU - darah (Jan-Jun 2009)RSDK ChlGenCipCtxCazDKBFOSMEMMFXSXTVAN Enterobacter.aerog enes Eschericia coli Pseudomonas aeroginosa Staphylococcus epidemidis Ruang Anak

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34 Contents Handling specimen 1 Diagnosis Laboratorium Infeksi 2 Peta medan kuman 3 Pemilihan AB berdasarkan sensitivitas test Mekanisme Resistensi

35 Pengamatan Hasil Pemeriksaan Mikrobiologi

36 Pengamatan Hasil Pengamatan Sebelum Terapi Empirik Spektrum luas De-escalating Data epidemiologi Narrow sp aman oost Sesudah Terapi Definitif

37 Use Antimicrobials Wisely Treat infection, not contamination Fact: A major cause of antimicrobial overuse is “treatment” of contaminated cultures. Actions: use proper antisepsis for blood & other cultures culture the blood, not the skin or catheter hub use proper methods to obtain & process all cultures  Link to: CAP standards for specimen collection and managementCAP standards for specimen collection and management 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

38 Use Antimicrobials Wisely Treat infection, not colonization Fact: A major cause of antimicrobial overuse is treatment of colonization. Actions: treat bacteremia, not the catheter tip or hub treat pneumonia, not the tracheal aspirate treat urinary tract infection, not the indwelling catheter  Link to: IDSA guideline for evaluating fever in critically ill adultsIDSA guideline for evaluating fever in critically ill adults 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

39 Follow Established Guidelines Consult Specialist Follow Guidelines

40 Use Local Data  Know your antibiogram  Know your formulary  Know your patient population  When infection is not diagnosed  When infection is unlikely Stop Antimicrobial Treatment

41 Hasil Kultur Darah Ruang Anak RSDK KumanJumlahProsentase Candida albicans % Enterobacter aerogenes % Escherichia coli146.3 % Pseudomonas aeruginosa % Salmonella typhi 41.8 % Staphylococcus aureus % Staphylococcus epidermidis % Streptococcus pneumoniae 20.9 %

42 Ampi-sulbactam Amikasin Kleb.pnem ( darah ) Pseudo.aero ( darah ) L :21.000L : Pasien sepsis dengan demam selama 10 hari.

43 Kultur Darah : Klebsiella pneumonia Kultur Darah 28/8/2010Hasil Kuman:Klebsiella Pneumonia Sensitif:Amikacin, cefepim. Imipenem, meropenem, sulbactam cefoperazon Resisten:Ampicilin, ceftazidim, kotrimoksasol, gentamycin, moxifloxacin Kultur Darah 4/9/2010Hasil Kuman:Escherichia Coli, > Sensitif:Cefepim. Gentamycin, Imipenem, meropenem, fosfomycin Resisten:Amikacin, Ampicilin, Ampicilin sulbactam, ceftazidim, kotrimoksasol, moxifloxacin Kultur Urin : Escherichia Coli

44 Kultur Darah : Pseudomonas aeroginosa Kultur Darah 7/9/2010Hasil Kuman:Pseudomonas aeruginosa Sensitif:Kotrimoksasol, meropenem Resisten:Amikacin, Ampicilin, Cefepim, gentamicin, moxifloxacin, fosfomycin

45 Pasien DSS mengalami : -Sepsis -VAP + Gagal Nafas -Perdarahan Sembuh Perawatan selama 2 bulan Invitro : Chloramphenicol = S Invivio : Pseudomonas tidak bisa dengan Chloramphenicol

46 Pasien dengan diare kronis Hasil Kultur feses : Escherichia coli EPEC (+), berarti memang didapatkan infeksi di saluran cerna

47 Contents Handling specimen 1 Diagnosis Laboratorium Infeksi 2 Peta medan kuman 3 Pemilihan AB berdasarkan sensitivitas test Mekanisme Resistensi

48 48 Mechanisms of antimicrobial resistance Antimicrobial agents are catagorized according to their principle mechanism of action 1.Interference with cell wall synthesis (  lactams, Glycopeptide agents) 2.Inhibition of protein synthesis (macrolide, tetracycline) 3.Interference with nucleic acid synthesis (fluoroquinolones, rifampin) 4.Inhibition of a metabolic pathway (trimetopim sulfamethoxazole) 5.Disruption of bacterial membrane structure (polymixin) Tenover FC. Am J Med 2006;119(6):S3-S10

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50 50 …mechanisms of antimicrobial resistance OrganismMech of resistclinicalimplications ________________________________________________________ Str pneumoniaealteration of PBPrelative resistant to  -lactam agents (pen cillin, cephalosp) alteration in the resistance to macrolide ribosomal binding site of antibiotics efflux pump to expelrelative resist to macro an antibiotics from the lide cyoplasm Pong AL. Pediatr Clin N Am 2005;52: Table. Pediatric bacterial pathogens, mechanisms of resist

51 51 …mechanisms of antimicrobial resistance  Pediatric bacterial pathogens, mechanisms of resist OrganismMech of resistclinicalimplications ________________________________________________________ S. Aureusalteration in theresistant to all  -lactams binding site of a specific transpeptidase (mecA) alteration at resistance to macrolides ribosomal binding and clindamycin site efflux pump to expelrelative resist to macro an antib from the cyopllide Pong AL. Pediatr Clin N Am 2005;52:869-94

52 52 …mechanisms of antimicrobial resistance  Pediatric bacterial pathogens, mechanisms of resist OrganismMech of resistclinicalimplications ________________________________________________________ Escherichia coli,  -lactamases with ceftazidim Klebsiellaactivity extendedresistant to cefotaxim, beyond ampic ceftriaxone, (ESBL)ceftazidim Enterobacter, chromosomal resistant to cefotaxim, Seratia, other  -lactamases that ceftriaxone Enterobacteriaceaeare deregulated andceftazidim hyperproduced (ampC) Pong AL. Pediatr Clin N Am 2005;52:869-94

53 53 …mechanisms of antimicrobial resistance  Pediatric bacterial pathogens, mechanisms of resist OrganismMech of resistclinicalimplications ________________________________________________________ Pseudomonas multipel  -lactamases resistant to cefotaxime aerugeach with activity ceftriaxone against different ceftazidim  -lactam antibiotics cell wall porin protein carbapenem resist deficient bacteria multiple efflux pumpsresistance to  -lactam to expel antib fromfluoroquinolones the cytoplasm Pong AL. Pediatr Clin N Am 2005;52:869-94

54 54 MAJOR ANTIBIOTIC RESISTANCE MECHANISMS  Produce antibiotic inactivating enzymes  Reduce intracellular antibiotic concentration  Alter antibiotic target site  Eliminate antibiotic target site

55 55 Table Major Antibiotic Resistance Mechanisms Resistance Mechanism Specific examplesAntibiotic's effected Produce antibiotic inactivating enzymes β-lactamase, extended spectrum β-lactamasesβ-lactamase Adenyl, phosphoryl or acetyl transferasesAminoglycoside Reduce intracelluler concentration of the antibiotic Efflux pumpMacrolides, tetracyclines, fluoroquinolones Reduce outer membrane permeabilityPenicillins, macrolides, fluoroquinolones Alter the antibiotic target site Altered penicillins binding proteinsβ-lactamases Change peptidoglycans terminiGlycopeptides Mutations in gyrases or topoisomerase genes tRNA methylases Fluoroquinolone Macrolides Eliminate the antibiotic target site Encode an alternative penicillin binding proteinMethicillin Produce less enzyme or an alternative enzymeTrimethoprim, Sulphonamides

56 Enzymatic destruction of drug Prevention of penetration of drug Alteration of drug's target site Rapid ejection of the drug Mechanisms of Antibiotic Resistance

57 Figure Antibiotic Resistance

58 Proses Resistensi bakteria  Mutation  Gene exchange  Selection  Transmission proses biologi alamiah

59 New Resistant Bacteria Mutations XX Emergence of Antimicrobial Resistance Susceptible Bacteria Campaign to Prevent Antimicrobial Resistance in Healthcare Settings Resistant Bacteria Resistance Gene Transfer

60 Mutation

61

62 R

63 Konjugasi Transduksi Gene exchange

64 R

65 R R R

66 Resistant Strains Rare x x Resistant Strains Dominant Antimicrobial Exposure x x x x x x x x x x Selection for antimicrobial-resistant Strains Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

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68 Selection

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72 Transmission

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74 Air Droplets Contact Water Food Blood Vectors

75 Antibiotic Selection for Resistant Bacteria

76 Rangkuman  Pemeriksaan mikrobiologi khususnya biakan dan sensitifitas test sangat berperan dalam menegakkan suatu penyakit infeksi  Handling dan koleksi spesimen haruslah mengikuti kaidah yang sudah ditentukan  Pelaporan peta medan kuman disetiap RS dengan rutin sangat mendukung dalam pengelolaan pasien infeksi di RS tersebut  Penentuan pemberian antibiotik berdasarkan hasil biakan haruslah hati-hati, mengingat kadang ada perbedaan antara invivo dan invitro

77 LOGO


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