Peran Uji Mikrobiologi & sensitivitas test

1. 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 103-104 mikrobaper 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. 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 Gejala Klinis mis. septicaemia, endocarditis, osteomyelitis meningitis, UTI, pneumonia pharyngitis Kondisi pasien Kuman patogen didapat dari kultur

6. Alur Pemeriksaan Mikrobiologi

7. Contents 1 Handling specimen Diagnosis Laboratorium Infeksi 2 3 Peta medan kuman 4 4 Pemilihan AB berdasarkan sensitivitas test Mekmnisme Resistensi 5

8. Diagnosis of Bacterial Infection Non-microbiological investigations Patient Clinical diagnosis Radiology Haematology Biochemistry 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 19:788-802, 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. 2001 125:1290-1294) • 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. Lab Mikrobiologi Darah Urin Turn Around Time Pus Tinja Sputum Handling specimen

22. Cara pengambilan, penyimpanan dan pengiriman bahan Petunjuk Umum 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 • 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

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

24. Culture diagnostic of typhoid 100 % patients with pos culture 9 0 8 0 7 0 bloods 6 0 stool 5 0 4 0 3 0 urine 2 0 1 0 0 • 2 3 4 5 6 7 8 • weeks

25. Contents 1 Handling specimen Diagnosis Laboratorium Infeksi 2 3 Peta medan kuman 4 4 Pemilihan AB berdasarkan sensitivitas test Mekanisme Resistensi 5

26. Laboratorium Mikrobiologi

27. Pemeriksaan Kultur Darah

30. Contents 1 Handling specimen Diagnosis Laboratorium Infeksi 2 3 Peta medan kuman 4 4 Pemilihan AB berdasarkan sensitivitas test Mekanisme Resistens 5

31. Hasil Peta Kuman – sensitivitas PICU-NICU - darah (Jan-Jun 2009)RSDK Ruang Anak

34. Contents 1 Handling specimen Diagnosis Laboratorium Infeksi 2 3 Peta medan kuman 4 4 Pemilihan AB berdasarkan sensitivitas test Mekanisme Resistensi 5

35. Pengamatan Hasil Pemeriksaan Mikrobiologi

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

37. 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Use Antimicrobials WiselyTreat 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 management

38. 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Use Antimicrobials WiselyTreat 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 adults

39. Follow Established Guidelines Consult Specialist Follow Guidelines

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

41. Hasil Kultur Darah Ruang Anak RSDK

42. Pasien sepsis dengan demam selama 10 hari. Pseudo.aero ( darah ) Kleb.pnem ( darah ) L :21.000 L : 8.300 Ampi-sulbactam Amikasin

43. Kultur Darah : Klebsiella pneumonia Kultur Urin : Escherichia Coli

44. Kultur Darah : Pseudomonas aeroginosa

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 1 Handling specimen Diagnosis Laboratorium Infeksi 2 3 Peta medan kuman 4 4 Pemilihan AB berdasarkan sensitivitas test Mekanisme Resistensi 5

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

49. 1 3 4 2 5

50. Table . Pediatric bacterial pathogens, mechanisms of resist …mechanisms of antimicrobial resistance Organism Mech of resist clinical implications ________________________________________________________ Str pneumoniae alteration of PBP relative resistant to -lactam agents (pen cillin, cephalosp) alteration in the resistance to macrolide ribosomal binding site of antibiotics efflux pump to expel relative resist to macro an antibiotics from the lide cyoplasm Pong AL. Pediatr Clin N Am 2005;52:869-94