Curriculum Vitae

Nama : Dr. Ronald Irwanto Natadidjaja, SpPD – KPTI, FINASIM

Pendidikan :
SMP - SMA : Kolese KANISIUS, lulus 1994
Dokter Umum : FK TRISAKTI, lulus 2002
Spesialis Penyakit Dalam (Internist) : FKUI, lulus 2009
Konsultan Penyakit Tropik & Infeksi : FKUI / PAPDI, lulus 2013

Pekerjaan :
Bendahara Pengurus Besar Perhimpunan Konsultan Penyakit Tropik dan Infeksi Indonesia (PB PETRI)

SekJen Pengurus Pusat Perhimpunan Pengendalian Infeksi Indonesia (PP. PERDALIN)

Tim Panel Ahli PNPK Sepsis, Kemenkes RI

Anggota Pokja PPI, Kemenkes RI

Kepala Bagian Ilmu Penyakit Dalam, FK TRISAKTI

Ketua PPRA, RS PONDOK INDAH – PURI INDAH dan RS PONDOK INDAH – BINTARO JAYA

Wakil Ketua Komite Medik, RS PONDOK INDAH – PURI INDAH

Internist - Konsultan, RS PONDOK INDAH – PURI INDAH dan RS PONDOK INDAH – BINTARO JAYA
 Ronald Irwanto Antimicrobial Stewardship Program (RASPRO) Indonesia

MIC-90
Dosis minimal yang dapat digunakan untuk mencegah
pertumbuhan 90% kuman IN VITRO (Standard CLSI )

RESISTENRELATIF

Contoh/
Cut off MIC-90 Resisten betalaktam = 32ug/ml

E.coli dinyatakan RESISTEN terhadap betalaktam apabila diberikan 32ug/ml

Beta Laktam IN VITRO BELUM BISA MENGHAMBAT PERTUMBUHAN 90%

QUESTION :
Bila diberikan AB 34ug/ml36ug/ml 38ug/ml SENSITIF

IN VIVO :
Diberikan 1x2 gram Ceftriaxone Resisten Diberikan 2x2g 3x2gSENSITIF??
 Mechanism of Antimicrobial Resistance:
“Selective Pressure” for Antimicrobial-Resistant Strains

Resistant Strains
Rare
Antimicrobial
Exposure

Resistant Strains
Dominant

Campaign to Prevent Antimicrobial Resistance in Healthcare

Settings, CDC 2002
 Cumulative Antibiogram : Indonesia VS Overseas
Antibiotik
SETTING 1 Indonesia
Antibiotik High
Antibiotik Resistance
Antibiotik Result
Microorganism
Culture Culture Culture Culture
Pattern

SETTING 2 Overseas
Antibiotik

Antibiotik High
Antibiotik Sensitive
Antibiotik Result
Microorganism
Culture Culture
Pattern
Culture Culture
 Ronald Irwanto Antimicrobial Stewardship Program (RASPRO) Indonesia

Antibiotik Profilaksis Bedah

Clean TANPA AB
Clean + Prothese
Clean Contaminated Profilaksis
Contaminated
Dirty Empirik
 IDO Limiting Time by CDC
• Superficial 30 days
• Organ Space 90 days
• Prothese 12 Months
Gelijns and colleagues (2014) published a detailed
study that found that prophylactic antibiotic use for
> 48 hours after cardiac surgery was associated with
an increased risk of CDI and other major infectious
complications. In addition, there was no difference
in infectious complications between patients
receiving postoperative antibiotics for 0 to 24 hours
or 24 to 48 hours, suggesting that 24 hours of
postoperative antibiotics may be as safe as, or safer
than, extended regimens.
Gelijns AC, Moskowitz AJ, Acker MA, Argenziano M, Geller NL, Puskas
JD, et al. Management practices and major infections after cardiac
surgery. J Am Coll Cardiol. 2014;64:372-81.
Poeran and colleagues6 performed an additional high-quality
study on this topic and explored the association between
the duration of prophylactic antibiotics, use of adjuvant
vancomycin, and the development of postoperative CDI
amongst 154,200 patients undergoing coronary artery
bypass grafting with or without valve surgery in the
Premier Perspective claims database. Similar to prior
studies, adjuvant use of vancomycin was not associated
with CDI.7 However, the incidence of CDI increased from
0.19% in patients treated with antibiotics for for 2 days
(extended group), and this difference remained statistically
significant after careful risk adjustment.
Poeran J, Mazumdar M, Rasul R, Meyer J, Sacks HS, Koll BS, et al.
Antibiotic prophylaxis and risk of Clostridium difficile infection after
coronary artery bypass graft surgery. J Thorac Cardiovasc Surg.
2016;151:589-97. e1-3.
 Implementing the ASP :
The RASPRO
Ronald Irwanto
Internist-Infectious Disease (ID) Specialist

Indonesian Society of Infection Control / PERDALIN

Trisakti School of Medicine
International Scientific Conference on AMR 2018 : MoH-Republic of Indonesia
IMPLEMETING ASP in PRIVATE HOSPITAL in INDONESIA

Formulating the ASP Concept :

The Rule of 3 PIE

Private Hospital Typical Difficulties in
Running ASP

• Managerial Support
• Internal Agreement
• Peer Group Consolidation

Commitment

Concept
How to Run the ASP??
 www.rasproindonesia.com
Ronald Irwanto Antimicrobial Stewardship Program (RASPRO) Indonesia

RASPRO Core Concept

Hospital
Clinician
/ Patient Safety
Insight
AGREEMENT Insight

Individual Community
ANTIMICROBIAL Approach
Approach
STEWARDSHIP PROGRAM

Antimicrobial Stewardship program is not about how to

restrict the broad spectrum but how to use antibiotic in
good!!
Ronald Irwanto, Hadi Sumarsono, RASPRO, RSPI Puri Indah,2013
What is RASPRO?
RASPRO is a concept for running ASP,
born in Pondok Indah-Puri Indah
hospital, a private hospital in Jakarta,
started in 2013

We, the team

noted all data and difficulties found in
field. Next, we did a further
discussion and synthesized more than
100 academic journals on all the
problem found,and formulating “THE
RULE of 3 PIE” as a conclusion for
Protected by
KEMENKUMHAM RI No. 000121541 implementing the ASP in hospital .
And, we implement it.
Intelectual Property Rights / We do :
Hak Kekayaan Intelektual dilindungi
FIX & OUT in running this program due to
Undang-undang no.28 Pasal 72 / 2014
the actual situation
 PINK BOX PURPLE BOX PEACH BOX

1. Promoting Guidelines (3) 2. Implementation (3) : 3. Evaluation (3) :

1. Disease Severity and 1. Strengthening Knowledge 1. Host :
Risk (Carmeli Conclusion) 1. Workshop 1. Hospital Stay
1. Type 1 2. Socialization 2. Cost
2. Type 2 3. Discussion 3. Mortality
3. Type 3 2. Controlling the Socio-Behavioral 2. Agent :
2. Antibiotic PK/PD 1. Credential 1. MDR-HAIs Incidence
1. Dose 2. Re-credential 2. Patient Colonization
2. Track 3. Restriction Program / 3. Environment
Consultation Regulation Colonization3.
3. Tissue Penetration
3. System (IT) 3. Compliance :
3. Microorganism Pattern
1. Guidelines breakdown 1. Define Daily Dose
1. Layer 1 : 3 T
(Quantitative)
1. Timing 2. IT / Bridging Flowchart
2. Technique 3. Guidance & Discussion
2. Gyssens
3. Transport
(Qualitative)
2. Layer 2 : 3 C
1. CLSI THE RULE of 3 PIE 3. Case Report
2. Completing plate
(Sporadic)
3. Completing MIC-90
Ronald Irwanto Antimicrobial
3. Layer 3 : 3 P
Stewardship Program (RASPRO) File
1. Proper Setting
RSPI-PURI INDAH
2. Proper Size
Copyright
3. Proper Percentage
International Scientific Conference on AMR 2018 : MoH-Republic of Indonesia
IMPLEMETING ASP in PRIVATE HOSPITAL in INDONESIA

The Rule of 3 PIE :

Promoting Guidelines
Predicting The MDR in Pneumonia
The ARUC Prediction
HCAP criteria (at least one of the following):
Previous hospitalization (3 months),
dialysis,
i.v. therapy previous 30 days,
residence in nursing home or long-term care facility

Bilateral Pulmonary Infiltration

Pleural effusion
PaO2/FiO2 < 300
 A score for predicting the risk of infection with resistant bacteria, including factors related to contact with the
healthcare environment as well as patients’ comorbidities, was computed (Table 4). The scores ranged from 0
to 12.5. Based on visual inspection, patients were grouped into low-risk and high-risk classes as a function of
their overall score (Figure 1). Among patients with a score ≤0.5 on entry, the prevalence of a resistant bacteria
was 8% (95% CI, 2%–13%), compared with 38% (95% CI, 25%–50%) in those with a score of ≥3 (P < .001). Figure
2 depicts the ROC curve for the score. The area under the ROC curve is 0.79 (95% CI, .71–.87). A score >0.5 was
associated with the best balance between sensitivity (0.75) and specificity (0.71).
Variable  Score 

No risk factors for MDR pathogen (including

0 
comorbidities) 

≥1 of the following: cerebrovascular disease, ALIBERTI SCORE :

Risk MDR Pathogen
diabetes, COPD, antimicrobial therapy in
preceding 90 days, immunosuppression, home 0.5 
wound care, home infusion therapy (including
antibiotics)  in Pneumonia

Residence in a nursing home or extended-care

3 
facility 

Hospitalization for ≥2 days in the preceding 90

4 
days 
Chronic renal failure  5 
 Gomila et al : Empiric Prediction of the
MDR in UTI
Gomila A et al dalam prediksi MDR pada infeksi saluran kemih
mempertimbangkan
- penggunaan antibiotik dalam < 30 hari
- penggunaan urin kateter, riwayat perawatan < 30 hari
- tindakan invasif < 30 hari
- jenis kelamin laki-laki
- serta riwayat infeksi saluran kemih dalam 1 tahun terakhir.

Gomila A, Shaw E, Carratala J. Predictive factors for multi-drug resistant gram negative
bacteria among hospitalized patients with complicated urinary tract infections.
Antimicrob Resist and Inf Contr, 2018 ;7:111
 Utility of a Clinical Risk Factor Scoring Model in Predicting Infection with
Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae on
Hospital Admission
Steven W. Johnson, PharmD,1,2 Deverick J. Anderson, MD, MPH,1 D. Byron May, PharmD,1,2
and Richard H. Drew, PharmD, MS1,2

• Italian Model (Tumbarello et al5)

Attribute No. of points

• Recent antibiotic therapy with β-lactams

< 90 days
and/or fluoroquinolonesa 2
• Previous hospitalizationb 3
• Transfer from another healthcare facility 3
• Charlson Comorbidity Score of ≥4 2
• Recent history of urinary catheterizationc 2
• Age ≥70 years 2

aDuring the 3 months preceding the index hospitalization. Infect Control Hosp
bDuring the 12 months preceding the index hospitalization. Epidemiol. 2013
cDuring the 30 days preceding the index admission. Apr; 34(4): 385–392.
 Utility of a Clinical Risk Factor Scoring Model in Predicting Infection with
Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae on
Hospital Admission
Steven W. Johnson, PharmD,1,2 Deverick J. Anderson, MD, MPH,1 D. Byron May, PharmD,1,2
and Richard H. Drew, PharmD, MS1,2

Duke Model
Attribute No. of points
Recent antibiotic therapy with β-lactams 3 < 90 days
and/or fluoroquinolonesa

Previous hospitalizationb 2

Transfer from another healthcare facility 4

Recent history of urinary catheterizationc 5

Immunosuppressiond 2 < 90 days

a
During the 3 months preceding the index hospitalization. Infect Control Hosp
b
During the 12 months preceding the index hospitalization. Epidemiol. 2013
c
During the 30 days preceding the index admission. Apr; 34(4): 385–392.
d
During the 3 months preceding the index admission.
Y. Carmeli,2014
 Carmeli Y Conclusion, 2014

Collateral Damage
 Ronald Irwanto Antimicrobial Stewardship Program (RASPRO) Indonesia
POLA KUMAN dari SPESIMEN URINE

ANTIBIOTIK dengan Penetrasi baik ke Saliuran Kemih

Golongan Penicillin :
Amoxycillin, Ampicillin, Amoxycillin Clavulanat, Ampicillin Sulbactam, Piperacillin Tazobactam
Golongan Cephalosporin :
Cephalosporin gen. III dan IV
Golongan Quinolon :
Ciprofloxacin
Golongan Carbapenem :
Ertapenem, Imipenem, Meropenem
Golongan lain :
Fosfomycin, Cotrimoxazole, Amikacin
 Urinary Tract Infection
1. Promoting Guidelines (3) REVIEW MODEL : GUIDELINES
1. Disease Severity and
Risk (Carmeli Conclusion) Stratification Type I :
1. Type 1
2. Type 2 Pilihan :
3. Type 3 Ceftriaxone / Cefotaxime
2. Antibiotic PK/PD
1. Dose Alternative :
2. Track Cefixime / Amoxycillin / Ampicillin
3. Tissue Penetration ATAU
3. Microorganism Pattern Cotrimoxazole
1. Layer 1 : 3 T
1. Timing Stratification Type II
2. Technique Ampicillin Sulbactam
3. Transport ATAU
2. Layer 2 : 3 C Ertapenem
1. CLSI
2. Completing plate
Stratification Type III :
3. Completing MIC-90
Meropenem / Imipenem +/- Ciprofloxacin /
3. Layer 3 : 3 P
Amikacin
1. Proper Setting
ATAU
2. Proper Size
Ceftazidime/Cefepime / Cefpirome +/-
3. Proper Percentage
Ciprofloxacin / Amikacin
International Scientific Conference on AMR 2018 : MoH-Republic of Indonesia
IMPLEMETING ASP in PRIVATE HOSPITAL in INDONESIA

The Rule of 3 PIE :

Implementation
IMPLEMENTATION
RASPRO 4 Forms :
The Bridging Flowchart
Form 1 : RASPRO Alur Antibiotik Awal (RASAL)
Done for every first empiric antibiotic prescription

Form 2 : RASPRO Alur Antibiotic Lanjutan (RASLAN)

Done for every antibiotic empiric escalation / de-escalation / addition

Form 3 : RASPRO Formulir Antibiotik Sesuai Kultur (RASPATUR)

Done for every culture findings based antibiotic prescription

Form 4 : RASPRO Formulir Antibiotic Berkepanjangan (RASPRAJA)

Done for every prolonged antibiotic prescription
(Time is based on internal agreement)
RASPRO Patient Stratification Synthesized from ARUC, Aliberti, Tumbarelo, Duke, Carmeli
 Ronald Irwanto Antimicrobial Stewardship Program (RASPRO) Indonesia

Immunocompromised
Bila terdapat SALAH SATU atau LEBIH di bawah ini

 Neonatus Berat Badan Lahir Rendah  Pasien-pasien geriatri dengan multipatologi

(BBLR) (>1banyak komorbid, termasuk infeksi yang
 Neonatus dengan kelahiran prematur diderita)
 Neonatus dengan multipatologi (banyak  Pasien-pasien dengan HIV / AIDS
komorbid)  Pasien-pasien dengan malignancy
(keganasan)
 Pasien-pasien dengan febrile netropenia
 Pasien-pasien dengan penyakit infeksi kronis
/infeksi kronis / sirosis hati dan gagal ginjal
kronis
 Pasien-pasien dengan autoimmune dan/atau
penggunaan immunosupresan lama
ARUC Score
Alberti et al

Tumbarelo Model
Duke Model
Infect Control Hosp
Epidemiol. 2013 :34(4): 385–392.

Gomila et al

Gomila A, Shaw E,
Carratala J. Predictive
factors for multi-drug
resistant gram
negativebacteria among
hospitalized patients with
complicated urinary tract
infections.
Antimicrob Resist and Inf
Contr, 2018 ;7:111

Carmeli conclusion
etc

Hak Cipta :
RASPRO Indonesia
Hak Cipta : RASPRO Indonesia
RASPRO Alur Antibiotik Lanjutan (RASLAN)

RASPRO
Indonesia
Formulir RASPRAJA
Formulir RASPRAJA (sambungan)
 Formulir Antibiotik Sesuai Kultur
(RASPATUR)
Ketentuan : Formulir diisi apabila antibiotik akan
diberikan sesuai kultur

Nama Pasien :
Nomor RM :

Antibiotik diberikan sesuai sensitifitas kultur kuman:

1.
2.
Nama : DPJP :

Mulai x/ Antibiotik 1 2 3 4 5 6 7
hari

Administering
RASAL Time

RASLAN Administering
Time
RASPRAJA

RASPRO Nurse Cardex

If >7 days
RASLAN Administering
Time

RASPATUR Administering
Time

For Watching the RASPRO Form

“Traffic”
Done for each Patient
Hak Cipta : RASPRO Indonesia
 Pemberian
Ruang
Nama Pasien Antibiotik Mulai Harus STOP tgl RASAL RASLAN RASPATURRASPRAJA
tgl (7 hari dari Alasan
tgl mulai) Berkepanjangan

RASPRO Pharmacist Cardex

For Watching the RASPRO Form

“Traffic”
Done for each Patient
Hak Cipta : RASPRO Indonesia
 www.rasproindonesia.com
RASPRO
Indonesia

• Seorang wanita 55 tahun dibawa keluarganya dengan

keluhan demam sejak 5 hari yang lalu. Nyeri BAK
dan sakit pinggang. Makan minum bisa, keadaan
umum baik
• Tanda klinis sepsis (-)
• Riwayat DM + tidak terkontrol
• Riwayat minum antibiotik terakhir 2 bulan yang lalu
saat pasien mengalami sakit tenggorokan
• Riwayat perawatan di RS sebelumnya disangkal
• Leukosit 11.800
Ampi
sulbac

RASPRO
Indonesia
 www.rasproindonesia.com
RASPRO
Indonesia

• 3 hari dengan pengobatan Ampicillin Sulbactam,

klinis belum membaik, panas makin tinggi, nadi
sangat cepat
• Tanda klinis sepsis (+)
• Riwayat DM + tidak terkontrol
• Pasien dalam antibiotik 3 hari terakhir
• Pasien dalam perawatan di RS 3 hari terakhir
• Leukosit 17.000
Ampi Meropenem
sulbac

RASPRO
Indonesia
International Scientific Conference on AMR 2018 : MoH-Republic of Indonesia
IMPLEMETING ASP in PRIVATE HOSPITAL in INDONESIA

The Rule of 3 PIE :

Evaluation(Qualitative) By Gyssens

How to Limitation the Subjective Bias :

RASPRO Matrix on Gyssens
Sample Formula :
N = (Zᾳ2 p.q)
d2
 AB
N HASI
PENGAMATAN KATEGORI TINDAKAN CATATAN
O L
I II III IV V
1 Data lengkap tidak VI henti
ya
2 Indikasi Antibiotik sesuai tidak V henti
ya
3 Alternatif lebih efektif ya Iva
tidak
4 Alternatif kurang toxik ya IV b
tidak
5 Alternatif lebih murah ya IVc
tidak
6 Alternatif lebih sempit ya IVd
tidak
7 Durasi terlalu panjang ya IIIa
tidak
8 Durasi terlalu singkat ya IIIb
tidak
9 Dosis tepat tidak IIa
ya
10 Interval tepat tidak IIb
ya
11 Rute tepat tidak IIc
ya
12 Waktu pemberian tepat tidak I
ya 0 Tepat
 Ronald Irwanto Antimicrobial Stewardship Program (RASPRO) Indonesia

Gyssens : Kategori VI-V

KATEGORI VI KATEGORI V
"DATA LENGKAP ?" "INDIKASI ANTIBIOTIK SESUAI ?"

RASPRO SISTEM RASPRO SISTEM

data tidak fokus infeksi tidak
lengkap data lengkap disebut fokus infeksi disebut

tidak ya tidak ya
 Ronald Irwanto Antimicrobial Stewardship Program (RASPRO) Indonesia

Gyssens : Kategori IVa

KATEGORI IVa
"ADAKAH ALTERNATIF LEBIH EFEKTIF?"

RASPRO SISTEM

kultur (-) / tidak sesuai kultur kultur (+) / sesuai kultur

sesuai di luar stratifikasi sesuai

RASAL/ RASAL/RASLAN RASAL / di luar stratifikasi di luar
RASLAN /PPAB RASLAN RASAL/RASLAN PPAB

tidak ya tidak tidak ya

 Ronald Irwanto Antimicrobial Stewardship Program (RASPRO) Indonesia

Gyssens : Kategori IVb

KATEGORI IVb

"ADAKAH ALTERNATIF KURANG TOXIK?"

RASPRO SISTEM
kultur (-) / tidak sesuai kultur kultur (+) / sesuai kultur
sesuai sesuai
RASAL / di luar RASAL / di luar
RASLAN RASAL/RASLAN/PPAB RASLAN RASAL/RASLAN/PPAB

telusur IVb RASPRO

(dibandingkan dengan AB telusur IVb RASPRO
tertera di PPAB sesuai (dibandingkan antar AB tertera
stratifikasi RASAL/RASLAN) di kultur)
kurang toxik kurang toxik
(-) kurang toxik (+) (-) kurang toxik (+)

tidak tidak ya tidak tidak ya

 Ronald Irwanto Antimicrobial Stewardship Program (RASPRO) Indonesia

Gyssens : Kategori IVc

KATEGORI IVc
"ADAKAH ALTERNATIF LEBIH MURAH?"

RASPRO SISTEM
kultur (-) / tidak sesuai kultur kultur (+) / sesuai kultur

sesuai sesuai
RASAL/R di luar RASAL / di luar
ASLAN RASAL/RASLAN/PPAB RASLAN RASAL/RASLAN/PPAB

telusur IVc RASPRO

(dibandingkan dengan AB
tertera di PPAB sesuai telusur IVc RASPRO
stratifikasi (dibandingkan antar AB
RASAL/RASLAN) tertera di kultur)
lebih murah lebih murah lebih murah
(-) (+) (-) lebih murah (+)

tidak tidak ya tidak tidak ya

 Ronald Irwanto Antimicrobial Stewardship Program (RASPRO) Indonesia

Gyssens : Kategori IVd

KATEGORI IVd
"ADAKAH ALTERNATIF LEBIH SEMPIT?"

RASPRO SISTEM
kultur (+) / sesuai
kultur (-) / tidak sesuai kultur kultur
stratifikasi
stratifikasi RASAL/RASLAN
sesuai stratifikasi RASAL/RASLAN lebih rendah/di
RASAL/RASLAN lebih tinggi luar PPAB

tidak tidak ya tidak

 Gyssens :Kategori IIIa-IIIb
KATEGORI IIIa
"DURASI TERLALU PANJANG ?"

RASPRO SISTEM
> 7 hari (form RASPRAJA +) ≤ 7 hari (form RASPRAJA +)

ya tidak

Catatan :
1. Hari durasi terlalu panjang disepakati menurut kesepakatan bersama.
2. Hari durasi terlalu panjang tetap berlaku walaupun antibiotik diberikan sesuai kultur.

KATEGORI IIIb
"DURASI TERLALU SINGKAT ?"

RASPRO SISTEM
< 3 hari (RASPRO cardex) ≥ 3 hari

ya tidak

Catatan :
1. Hari durasi terlalu singkat disepakati menurut kesepakatan bersama, berlaku untuk semua
kasus pemberian
antibiotik empirik yang dihentikan pemberiannya dalam waktu kurang dari waktu yang
ditentukan, apapun
penyebabnya.
2. Hari durasi terlalu singkat tetap berlaku walaupun antibiotik diberikan sesuai kultur.
 Gyssens :Kategori IIa-IIb-IIc
KATEGORI IIa
"DOSIS TEPAT ?"

RASPRO SISTEM
sesuai PPAB tidak sesuai PPAB

ya tidak

KATEGORI IIb
"INTERVAL TEPAT ?"

RASPRO SISTEM
sesuai PPAB tidak sesuai PPAB

ya tidak

KATEGORI IIc
"RUTE TEPAT ?"

RASPRO SISTEM
sesuai telusur RASPRO IIc tidak sesuai telusur RASPRO IIc

ya tidak
 Gyssens : Kategori I-0
KATEGORI I
"WAKTU PEMBERIAN TEPAT ?"

RASPRO SISTEM
tidak sesuai waktu
sesuai waktu pemberian
pemberian

ya tidak

Catatan :
Dikatakan kategori 0 (Pemberian Antibiotik Tepat),
apabila tidak terkategori tertentu sebelumnya/di
atasnya.
International Scientific Conference on AMR 2018 : MoH-Republic of Indonesia
IMPLEMETING ASP in PRIVATE HOSPITAL in INDONESIA

RASPRO Resume
 PINK BOX PURPLE BOX PEACH BOX
PROMOTING IMPLEMENTATION EVALUATION
Guidelines Guidelines
Patient Watched by RASPRO Nurse CARDEX
Stratification (For Each Patient) Host
Type I
Type II
Type III AB
First AB Change or Add Prescription
>7 Days Micro
Prescription AB Prescription By Culture
Antibiotic Culture AB Usage
PK/PD Organism
Taking
RASLAN
-Dose Form
-Track RASAL RASLAN RASPATUR
RASPRAJA FORM
-Tissue Form Form Form /
Penetration RASLAN
AUTOMATIC Antibiotic
Form
Stop Order Compliance
Cumulative
Antibiogram Restrict when it’s not DDD
-Timing proper to the RASPRO Gyssens
- Complete Stratification Integrative
--Proper Watched by RASPRO Pharmacist CARDEX Case Report
(For Each Patient)
ern of Skin & Soft tissue infection microorganism
n from 3 emergency room in Jakarta
d Irwanto (INASIC) et al
hed in poster session, ISAAR, Bangkok 2009
Culture-and non culture-based antibiotics for complicated
soft tissue infections are comparable
Ronald Irwanto (INASIC) et al
Published in Universa Medicina 2013 : 32(1) : 20-28

Antibiotic treatment based on Guidelines for Reducing Length of Stay

(LOS) in Patients with Community Acquired Pneumonia
FC. Munarsih, Ronald Irwanto (INASIC), Syamsudin
Published in Jurnal Penyakit Dalam Indonesia
Indonesian Journal of Internal Medicine 2018 : 5(3) : 141-8
Hubungan antara Kadar Procalcitonin dengan Serum Transaminase pada Pasien
Sepsis : Sebuah Studi Pendahuluan
Nurhadi Kuswoyo, Ronald Irwanto published in Journal Biomedkes 2019

Empiric prediction to culture and Define Daily Dose (DDD) after RASPRO
Ronald Irwanto, Djoko Widodo, Hadi Sumarsono
In progress publication

Survey Persepsi terhadap Kebutuhan dan Kesulitan Rumah Sakit dalam

Menjalankan Fungsi Panitia Pengendalian Resistensi Antibiotik
Ronald Irwanto, Djoko Widodo,, Aziza Ariyani, Hadianti Adlani
In progress publication
 PERMENKES 8 / 2015
BAB II
STRATEGI
Pasal 3
Strategi Program Pengendalian Resistensi Antimikroba dilakukan dengan cara:
a. mengendalikan berkembangnya mikroba resisten akibat tekanan seleksi
oleh antibiotik, melalui penggunaan antibiotik secara bijak; dan
b. mencegah penyebaran mikroba resisten melalui peningkatan ketaatan
terhadap prinsip pencegahan dan pengendalian infeksi.

PERDALIN- RASPRO : perpanjangan teori selective pressure (tekanan

selektif) yang diejawantahkan dalam bentuk implementasi flowcart yang
memandu klinisi kapan menggunakan antibiotik spektrum luas dan kapan
menggunakan antibiotik spektrum sempit
Empirical Prediction :
Aliberti, Shorr Score, Tumbarelo et al, Duke, Gomila et al, Carmeli conc.
Pasal 4
(1) Penggunaan antibiotik secara bijak d meningkatkan pelayanan farmasi
sebagaimana dimaksud dalam Pasal 3
klinik dalam memantau penggunaan
huruf a merupakan penggunaan antibiotik
secara rasional dengan antibiotik;
mempertimbangkan dampak muncul dan e. meningkatkan pelayanan farmakologi klinik
menyebarnya mikroba (bakteri) resisten. dalam memandu penggunaan antibiotik;
(2) Penerapan penggunaan antibiotik secara meningkatkan penanganan kasus infeksi secara
bijak sebagaimana dimaksud pada ayat (1) multidisiplin dan terpadu;
dilakukan melalui tahapan: g. melaksanakan surveilans pola penggunaan
a. meningkatkan pemahaman dan ketaatan antibiotik, serta melaporkannya secara berkala;
staf medis fungsional dan tenaga dan
kesehatan dalam penggunaan antibiotik h. melaksanakan surveilans pola mikroba
secara bijak; penyebab infeksi dan kepekaannya terhadap
b. meningkatkan peranan pemangku antibiotik, serta melaporkannya secara berkala
kepentingan di bidang penanganan
penyakit infeksi dan penggunaan Sosialisasi
Kultur & Pola Kuman
antibiotik;
c. mengembangkan dan meningkatkan PERMENKES 8 / 2015
Evaluasi Farmasi
fungsi laboratorium mikrobiologi
Caseklinik dan multidisiplin
Report
laboratorium penunjang lainnya yang
berkaitan dengan penanganan penyakit
infeksi;
 Bagian
PERMENKES 8 / 2015 Kesatu
Umum
Pasal 6
(1) Setiap rumah sakit harus melaksanakan Program Pengendalian Resistensi Antimikroba
secara optimal.
(2) Pelaksanaan Program Pengendalian Resistensi Antimikroba sebagaimana dimaksud
pada ayat (1) dilakukan melalui:
Pembentukan
a.pembentukan tim pelaksana PPRA RSResistensi Antimikroba;
program Pengendalian
b.penyusunan kebijakanPPAB / Antibiotic
dan panduan Guidelines
penggunaan antibiotik;
PPI dan
c.melaksanakan penggunaan antibiotik PPRA
secara bijak;
d.melaksanakan prinsip pencegahanImplementasi
pengendalian infeksi.
(3) Pembentukan tim pelaksana Program Evaluasi
Pengendalian Resistensi Antimikroba rumah
sakit sebagaimana dimaksud pada ayat (2) huruf a bertujuan menerapkan Program
Pengendalian Resistensi Antimikroba di Rumah Sakit melalui perencanaan,
pengorganisasian, pelaksanaan, monitoring, dan evaluasi.
(4) Penyusunan kebijakan dan panduan penggunaan antibiotik, melaksanakan
penggunaan antibiotik secara bijak, dan melaksanakan prinsip pencegahan
pengendalian infeksi sebagaimana dimaksud pada ayat (2) huruf b, huruf c, dan huruf
d dilakukan sesuai dengan ketentuan peraturan perundang-undangan.
Pasal 7-10 tentang Pembentukan PPRA RS dan Tugas-Tugasnya
 PERMENKES 8 / 2015
Indikator Mutu
Pasal 11
Indikator mutu Program Pengendalian Resistensi Antimikroba di Rumah Sakit
meliputi:
a. perbaikan kuantitasDDDpenggunaan antibiotik;
b. perbaikan kualitas penggunaan antibiotik;
Gyssens
Pola Kuman-HAIs
c. perbaikan pola kepekaan Incidence
antibiotik dan penurunan pola resistensi
Case Report multidisiplin
antimikroba;
d. penurunan angka kejadian infeksi di rumah sakit yang disebabkan oleh
mikroba multiresisten; dan
e. peningkatan mutu penanganan kasus infeksi secara multidisiplin, melalui
forum kajian kasus infeksi terintegrasi.
 PINK BOX PURPLE BOX PEACH BOX

1. Promoting Guidelines (3) 2. Implementation (3) : 3. Evaluation (3) :

1. Disease Severity and 1. Strengthening Knowledge 1. Host :
Risk (Carmeli Conclusion) 1. Workshop 1. Hospital Stay
1. Type 1 2. Socialization 2. Cost
2. Type 2 3. Discussion 3. Mortality
3. Type 3 2. Controlling the Socio-Behavioral 2. Agent :
2. Antibiotic PK/PD 1. Credential 1. MDR-HAIs Incidence
1. Dose 2. Re-credential 2. Patient Colonization
2. Track 3. Restriction Program / 3. Environment
Consultation Regulation Colonization3.
3. Tissue Penetration
3. System (IT) 3. Compliance :
3. Microorganism Pattern
1. Guidelines breakdown 1. Define Daily Dose
1. Layer 1 : 3 T
(Quantitative)
1. Timing 2. IT / Bridging Flowchart
2. Technique 3. Guidance & Discussion
2. Gyssens
3. Transport
(Qualitative)
2. Layer 2 : 3 C
1. CLSI THE RULE of 3 PIE 3. CaseReport/
2. Completing plate
Prospective audit
3. Completing MIC-90
Ronald Irwanto Antimicrobial (Sporadic)
3. Layer 3 : 3 P
Stewardship Program (RASPRO) File
1. Proper Setting
RSPI-PURI INDAH
2. Proper Size
Copyright
3. Proper Percentage
RASPRO Application Rule

Restricted when AB not proper with the

stratification (RASAL-RASLAN Form) by system &
PPRA

Culture based form (RASPATUR) when de-Escalation

done by definitive result

Automatic Stop Order done when prolong used

occurred without any adequate reasons
(RASPRAJA Form)
Technical Guidance for PERDALIN-RASPRO
Implementation has been done in a few hospitals in Indonesia
both Private & Government

JAKARTA Province of West Sumatera

National Cardiac Center Harapan Kita Hospital National Stroke Bukit Tinggi Hospital
Tebet Government General Hospital
Cempaka Putih Government General Hospital Province of West Java
Pasar Rebo Government General Hospital Bandung Adventist Hospital
Hermina Group Hospitals Immanuel Hospital
Sayang Cianjur Hospital
Province of Central Java

Province of East Borneo Tjitrowardojo Government General

Hospital
AW.Sjahranie Government General Hospital Mardi Rahayu Hospital, Kudus
Province of East Java
Province of Jambi Dr. Soedono Government General Hospital
Madiun
HAMBA Government General Hospital Dr. Sudomo, Government General Hospital,
Trenggalek
Ronald Irwanto & Yehuda Carmeli
Manila, Philippines 2014
Presentasi RASPRO Concept di Kemenkes RI
International Scientific Conference on AMR :
Ministry of Health Republic of Indonesia in Conjunction with WHO
Jakarta, 29 November 2018, Ronald Irwanto
 WORKSHOP PERDALIN ARTS-3

Metode RASPRO :
Pembuatan Panduan AB
Latihan dengan berbagai penyulit

(Dihadiri ketua-ketua cabang

PERDALIN juga anggota
Perhimpunan Peneliti Penyakit Tropik dan
Infeksi Indonesia (PETRI)

WORKSHOP Early Exposure 2 Ways

Dialogue
(Metode RASPRO-EE2D)
Perhimpunan Dokter Spesialis
Patologi Klinik (PDS-PATKLIN )
Jakarta

www.rasproindonesia.com
Ronald Irwanto,
Antimicrobial Resistance Fighter
Coalition, 2018
Indonesia…Champion!!!