Curiculum Vitae (CV) M.D, Franciscus Ginting (Faculty of Medicine Universitas Sumatera Utara, Indonesia) Franciscus Ginting is a Internal Medicine, works at the Departement of Internal Medicine of Adam Malik Hospital /Faculty of Medicine Universitas Sumatera Utara, Medan, Indonesia. After acquiring his medical degree (M.D), he completed postgraduate degree (Magister Kesehatan) in field Internal medicine from Universitas Sumatera Utara & his clinical training in Internal medicine (SpPD) at Adam Malik Hospital/Faculty of Medicine Univeristas Sumatera Utara. Since 2017, he has been involved as a head of Antimicrobial stewardship programme (ASP) of at Adam Malik Hospital a tertiary hospital Medan. Now he is become a PhD student at the Academic Medical Center of the University of Amsterdam under SPIN-KNAW project, entitled: Novel strategies and tools for antimicrobial resistance surveillance. His PhD research focuses on Validation and application of Lot Quality Assurance Sampling (LQAS) to estimate prevalence of antimicrobial drug resistance.
Appropriate Antimicrobial Treatment for Complicated Skin & Soft Tissue Infection (CSSTI) By : dr. Franciscus Ginting, Sp.PD KPTI
Introduction Incidence of SSTI 2005 2010 more than 3 millions comes to ER (increase from preceding 15 years) Septic cssti 4,3% - 10,5% United States hospitalised SSTI : 58,6 % superficial infection (Uncomplicated SSTI) and 41,4 % deeper infection (complicated ssti) 2% 5,8 % hospitalised SSTI admitted to the ICU 0,4 % SSTI admitted to the ICU with 60 % are necrotizing fasciitis (fatal infection) Asian limited data China in 2008 2013 (Xiaoman study) : 527 cases cssti 61,4 % are gram + - ve and 46,20 % are gram - ve Taiwan 53-83 % SSTI are caused by MRSA Indonesia : 2010 : Cipto Mangunkusumo Hospital : o cssti >10% of cases. o bacteria 74,3% gram - ve bacteria ( 19,5% pseudomonas sp). 2016: H. Adam Malik Hospital,Medan SSTI is the 3 rd common cause of sepsis (12,8%) after Pneumonia (56,5%) and UTI (16,5%)
Classification SSTI SSTI Uncomplicated infections are superficial Often self-limiting Can usually be treated successfully by incision and drainage alone or in combination with oral antibiotics 1. Impetigo 2. Abses cutaneus 3. Furunkel & Carbuncle 4. Erisepelas 5. Selulitis(mild) Complicated Infection extend to subcutaneous tissue, fascia or muscle Life treatening Required complex treatment with combined antibiotic and need surgical intervention 1. Surgical site infection 2.Ulcus decubitum 3. Trauma 4. Bite wound infection 5. Ulkus diabeticum 6. Fournier Ganggren 7. Infection cause necrotizing : Pyomyisitis Necrotizing Fascitis Clostridial necrotizing
Pathogenesis
Diagnosis of cssti
Diagnostic
Culture Indicated for the patient who presents exudates or abscess and requires operative incision and drainage after debridement and cleansing of necrotic tissues. Traditional culture : delay the result Superficial techniques: commensal microba The sensitivity of blood cultures, especially in patients with cellulitis low. Tissue biopsies after deep debridement advancing margin of the lesion specimen of choice Pus on a surface swab inadequate and does not represent the disease process. Imaging Plain radiography: gas in the soft tissue, osteomyelitis low accuracy US :guidance diagnostic ( aspiration),differentiate cellulites/abscess CT: guide fluid aspiration MRI: differentiates cellulitis/abscess, Detecting necrosis, inflammatory edema/muscular/fascia involvement
MANAGEMENT Early and precise diagnostic Determination of severity Complication Risk factor Identification of cause pathogen Incision, drainage Surgical debridement Broad spectrum AB Supportive care
Definition appropriate antimicrobial Empirical AM (before culture) = sensitive ( in culture results) Guidelines? Local antibiogram Decreasing mortality and morbidity
Antibiotic appropriate effect on cssti Study Irwanto R, Suhendro, Khie Chen Culture and non culture based AB cssti are comparable 26 gram positive,59 gram negative: retrospective, sepsis and non sepsis combined P =0,45 Jorg J Ruhe:cSSTI impact of Antimicrobial therapy on outcome Marcus J Zervos: Epidemiology and Outcomes of cssti Schramm GE: Theimpotnce of appropriate initial antimicrobial treatment The UK s National Institute for Clinical Excellence 531 cases episode cssti Appropriate 87% success Non-appropriate:87% failure treatment 366 (81,5%) appropriate 83(18,5%)not appropriate Same Younger, MRSA, drug Abuse 492 patients Appropriate : 95% succes Non-appropriate : 87% succes P=0,001 recommends monitoring of clinical progress and reassessment of treatment based on culture findings The Infectious Diseases Society of America recommends bacterial culture assessment to aid the selection of antibiotics against the causative pathogens and initiate definitive
IDSA 2014 Recommendation
Risk factors for different bacterial cssti Methicillin-resistant Staphylococcus aureus Anamnestic factors : Previous colonization Contact with patients colonized Antibiotic therapy in the prevous 12 months Hospitalization in the previous 12 months History of previous infection Recent travel in Latin,America,Africa,South East Asia Residence in long term care facilities Previous Intensive care unit admission Co-morbidities: Cardiovascular disease Diabetes Mellitus Perpheral vascular disease Chronic wounds Immunodepression Central venous catheter Chronic renal disease Dialysis Intravenous drug abuse Age >75 Male Intra- hospital transfer Hospitalization 1 year History of IV th/1year Gram-negative, anaerobes and polymicrobial Surgical site infection: Axillary cavity Exposure to carbapenem Exposure to fluoroquin Exposure to cephalosporin Indwelling catheter TOTAL > 5 Gastrointestinal tract Perineum Female genital tract Co- morbidities : Diabetes mellitus Cirrhosis Intravenous drug abuse Subcutaneous drug abuse
Cellulitis Very early and mild : oral beta lactam Severe: parenteral AB Cafazolin Vancomycin + piperacilin tazobactam or imipenem-meropenem (IDSA)
SSI No systemic sign : incision & drainage (most important) Significant systemic response: antibiotic treatment Vancomycin : increase MIC <0,5 2mg/ml Linezolid: o prospective study = vancomycin o open label study : vancomycin lower cure rate- 67% o many studies: more effective than vancomycin o Inhibit toxin production o Oral agent
Necrotizing infection Pyomyositis: purulent, skeletal muscle, arise from hematogenous spread, usually with abscess formation Incision + drainage AB: - aztreonam, fluoroquinolon, aminoglycoside, 4 th cephalosporin alone or combination - 1 st cephalosporin + anti ESBL - Anti MRSA Clostridial myonecrosis ( produce gas gangrene) PNC + clindamycin
Type of infection Necrotizing fasciitis by mixed pathogen Ampicillin sulbactam + Clindamycin + ciprofloxacin OR Piperacillin/tazobactam OR Fluorpquinolon OR Carbapenem OR 3 rd Cephalosporin OR Aminiglycoside +anti anaerobic agent Necrotizing fasciitis by GABHS(GroupA Beta hemolytic Sterptoccoccus) Necrotizing fasciitis by S. aureus Necrotizing Fasciitis PNC + clindamycin OR Glycopeptide OR Linezolid OR Tigecyline OR Daptomycin OR Dalbavancin 1 st cephalosporin OR Glycopeptides OR Linezolid OR Tigecyline OR Daptomycin OR Dalbavancin Necrotizing fasciitis Synergystic aerob &an aerob Antibiotic Choice Imipenem Meropenem Piperacillin / tazobactam PNC allergi Cefepime + Metronidazole Ciprofloxacin + Metronidazole + Vancomycin /Daptomycin
Pola Resistensi Kuman Rumah sakit Tipe A intensif Pola Resistensi Kuman gram negative PUS : Rumah sakit Tipe A Intensive
Pola Resistensi Kuman gram negative - LUKA : Rumah sakit Tipe A Intensive
Pola Resistensi Kuman gram negative - PUS : Rumah sakit Tipe A non Intensive
Pola Resistensi Kuman gram positive - PUS : Rumah sakit Tipe A non Intensive
Pola Resistensi Kuman Pus: Rumah sakit Tipe B non intensif
Pola Resistensi Kuman Pus: Rumah sakit Tipe C non intensive & Intensive
n % Amikasin Ampisilin sulbacatam Ceftriaxone ceftazidime clindamisin cefazoline cefoperazone - sulbactam ciprofloksasin cotrimoksazole doksisiklin gentamisin Levofloksasin meropenem tetracycline piperacilin - tazobactam imipenem vancomysine Pola Resistensi Kuman SSTI RSUP H Adam Malik non intensif dan intensif SSTI Resistance ALL gram negative bacteria 40 100 17,5 100 82,5 77,5 100 100 55 95 100 82,5 75 85 62,5 100 87,5 82,5 100 E.coli 4 10 0 100 100 100 0 100 25 100 100 0 50 100 0 100 100 75 0 K.pneumonia 9 22,5 11,1 100 100 100 0 100 83 100 100 0 100 100 55,6 100 88,9 77,8 0 Pseudomonas aeruginosa Acinetobacter baumanii Proteus mirabilis Enterobacter cloaceae Aeromonas hydrophilia 3 7,5 33 100 100 33 0 100 67 33 100 0 0 67 67 100 33 67 0 15 37,5 33 100 100 100 0 100 73 100 100 5 93 100 93 100 100 100 0 2 5 0 100 0 0 0 100 0 100 100 0 0 0 0 100 50 100 0 1 2,5 0 100 0 0 0 100 0 100 100 1 0 0 100 100 100 0 0 3 7,5 0 100 33 33 0 100 33 100 100 1 67 33 67 100 100 33 0 Serratia ficaria 1 2,5 0 100 100 100 0 100 0 100 100 0 100 100 100 100 100 100 0 Providentia stuartii Morganella Morgani 1 2,5 0 100 0 0 0 100 0 100 100 0 100 100 0 100 0 100 0 1 2,5 0 100 0 0 0 100 0 100 100 0 100 100 0 100 100 100 0
n % Amikasin Ampisilin sulbacatam Ceftriaxone ceftazidime clindamisin cefazoline cefoperazone - sulbactam ciprofloksasin cotrimoksazole doksisiklin gentamisin Levofloksasin meropenem tetracycline piperacilin - tazobactam imipenem vancomysine SSTI Resitance All bacteria gram + 8 100 100 87,5 87,5 1 62,5 87,5 100 87,5 87,5 87,5 1 87,5 100 75 100 100 37,5 Staphylococc us Sp. 5 62,5 100 80 80 1 40 80 100 80 80 80 1 80 100 40 100 100 40
S. hemolitikus 1 12,5 100 100 100 100 100 100 100 100 100 0 100 100 100 100 100 100 100 S.aureus 1 12,5 100 0 0 0 0 0 100 0 0 100 0 0 100 0 100 100 0 S.hominis 1 12,5 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 S.pseud 1 12,5 100 100 100 100 0 100 100 100 100 100 100 100 100 0 100 100 0 S.epidermidis 1 12,5 100 100 100 100 0 100 100 100 100 100 100 100 100 100 100 100 0 Enterococcus Sp 3 37,5 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 33 E. faecium 2 25 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 50 E.faecali 1 12,5 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 0
Checklist for early discharge of patients with acute bacterial skin and skin-structure infection
Kesimpulan 1. cssti penyakit yang serius 2. Penanganan cssti adalah menghilangkan source infeksi dan pemberian antibiotik 3. Pemberian antibiotik berdasarkan fokus infeksi dan stratifikasi faktor resiko MDR 4. Antibiotik appropriate mengurangi mortalitas dan morbiditas 5. Antibiotik appropriate memerlukan data lokal