k.9 Resistensi Antimikroba1

ANTIMIKROBAANTIMIKROBADAN UJI KEPEKAANDAN UJI KEPEKAAN

dr. Evita Mayasari, MKes.dr. Evita Mayasari, MKes.

Medical Faculty, University of Sumatera Medical Faculty, University of Sumatera UtaraUtara

OBAT ANTIMIKROBAOBAT ANTIMIKROBA

Obat Obat yang digunakan untuk menghambat yang digunakan untuk menghambat pertumbuhan dan atau membunuh bakteri pertumbuhan dan atau membunuh bakteri penyebab infeksi yang dapat diberikan per penyebab infeksi yang dapat diberikan per oral, parenteral atau lokal sebagai obat oral, parenteral atau lokal sebagai obat luar.luar.

Antibiotika bahan yang dihasilkan oleh Antibiotika bahan yang dihasilkan oleh “biotik” atau ma“biotik” atau makkhluk hluk hidup/mikroorganisme seperti Bakteri, hidup/mikroorganisme seperti Bakteri, Actinomycetes, jamur.Actinomycetes, jamur.

22dr. Edhie Djohan Utama, SpMK.dr. Edhie Djohan Utama, SpMK.

ANTIMIKROBAANTIMIKROBA

ANTIBIOTIKA ANTIBIOTIKA CHEMOTHERAPEUTIKACHEMOTHERAPEUTIKA ANTI FUNGUSANTI FUNGUS ANTI VIRUSANTI VIRUS

ANTISEPTIKA ANTISEPTIKA DESINFEKTANSIADESINFEKTANSIA


PENEMUAN AWAL ANTIMIKROBAPENEMUAN AWAL ANTIMIKROBA SALVARSAN : SALVARSAN : ditemukan pada awal tahun ditemukan pada awal tahun

1900 oleh Paul Ehrlich untuk pengobatan 1900 oleh Paul Ehrlich untuk pengobatan penyakit Syphilis.(Noble Prize)penyakit Syphilis.(Noble Prize)

PRONTOSIL (Sulfonamide)PRONTOSIL (Sulfonamide) Oleh Gerard Oleh Gerard Domagk 1927 dan penggunaannya tahun Domagk 1927 dan penggunaannya tahun 1935 (Noble Prize)1935 (Noble Prize)

SULFADIAZINE 693 = SulfanilamideSULFADIAZINE 693 = Sulfanilamide oleh oleh British Team pimpinan A.J.Evans tahun British Team pimpinan A.J.Evans tahun 19381938

PENICILLINPENICILLIN oleh Alexander Fl oleh Alexander Fleemming mming tahun 1929 dan penggunaannya tahun tahun 1929 dan penggunaannya tahun 1940 (Noble Prize)1940 (Noble Prize)

NYSTATINNYSTATIN : antifung: antifungalal pertama dijumpai pertama dijumpai tahun 1949 oleh Elisabeth Hazen & Browntahun 1949 oleh Elisabeth Hazen & Brown

STREPTOMYCINSTREPTOMYCIN oleh Selman Waksman oleh Selman Waksman tahun 1940 (Noble Prize)tahun 1940 (Noble Prize)

44

MIKROORGANISME YANG MIKROORGANISME YANG MENGHASILKAN AMENGHASILKAN ANTINTIMIKROBAMIKROBA

BakteriBakteriActinomycetes (2100) (Streptomyces)Actinomycetes (2100) (Streptomyces)(400) (Genus Bacillus)(400) (Genus Bacillus)

Fungi (800) Fungi (800) (Mold = Penicillium & Cephalosporium)(Mold = Penicillium & Cephalosporium)

AlgaeAlgaeProtozoaProtozoa


JENIS DAN CARA KERJAJENIS DAN CARA KERJA ANTIMIKROBAANTIMIKROBA

Menghambat sintesMenghambat sintesisis dinding seldinding sel bakteribakteri

Merusak permeabilitas Merusak permeabilitas membran membran sisitoplasma toplasma

Menghambat sintesMenghambat sintesisis proteinprotein..Menghambat sintesMenghambat sintesisis asam nuasam nukkleat.leat.


PENICICLLIN (Mold = PENICICLLIN (Mold = Penicillium)Penicillium) PNC-G dan Penicillin VPNC-G dan Penicillin V Methicillin, Oxacillin, Cloxacillin, DicloxacillinMethicillin, Oxacillin, Cloxacillin, Dicloxacillin Ampicillin & Amoxacillin, Carbenicillin, Ticarcillin, Ampicillin & Amoxacillin, Carbenicillin, Ticarcillin,

Piperacillin, MezlocillinPiperacillin, Mezlocillin CEPHALOSPORIN (CEPHALOSPORIN (mold = mold = CephalosporiumCephalosporium))

Gen.I : Cefachlor, Cephalothin, CephalexinGen.I : Cefachlor, Cephalothin, Cephalexin Gen.II : Cefuroxim, Cefixime, CefoxitinGen.II : Cefuroxim, Cefixime, Cefoxitin Gen.III : Cefotaxime, Ceftriaxone, CefoperazonGen.III : Cefotaxime, Ceftriaxone, Cefoperazon Gen.IV : Cefepime, CefpiromGen.IV : Cefepime, Cefpirom

CARBAPENEM CARBAPENEM : Imipenem & Meropenem: Imipenem & Meropenem MONOBACTAM MONOBACTAM : Aztreonam: Aztreonam GLYCOPEPTIDEGLYCOPEPTIDE : Vancomycin dan Teichoplanin : Vancomycin dan Teichoplanin CYCLOSERINECYCLOSERINE : : second line anti tbcsecond line anti tbc BACITRACINBACITRACIN : Untuk : Untuk infeksi kulit infeksi kulit superfisuperfissialial 77

PENICILLIN GROUPPENICILLIN GROUP Penicillins:Penicillins: penicillin G (Pfizerpen; Bicillin; Wycillin), penicillin G (Pfizerpen; Bicillin; Wycillin),

penicillin V (Betapen; Pen-Vee K), methicillin (Staphcillin), penicillin V (Betapen; Pen-Vee K), methicillin (Staphcillin), ampicillin (Omnipen; Polycillin), oxacillin (Bactocill ), ampicillin (Omnipen; Polycillin), oxacillin (Bactocill ), amoxicillin (Amoxil; Biomox; Polymox), ticarcillin (Ticar), amoxicillin (Amoxil; Biomox; Polymox), ticarcillin (Ticar), carbenicillin (Geocillin), piperacillin (Pipracil), mezlocillin carbenicillin (Geocillin), piperacillin (Pipracil), mezlocillin (Mezlin), bacampicillin (Spectrobid), dicloxacillin (Dynapen), (Mezlin), bacampicillin (Spectrobid), dicloxacillin (Dynapen), nafcillin (Nallpen; Unipen).nafcillin (Nallpen; Unipen).

Penicillins plus Penicillins plus ββ--lactamase inhibitorslactamase inhibitors or compounds or compounds preventing antibiotic degradation on the kidneyspreventing antibiotic degradation on the kidneys: : amoxicillin + clavulanate (Augmentin), amoxicillin + clavulanate (Augmentin), ticarcillin + clavulanate (Timentin), ticarcillin + clavulanate (Timentin), ampicillin + sulbactam (Unasyn), ampicillin + sulbactam (Unasyn), piperacillin + tazobactam (Zosyn), piperacillin + tazobactam (Zosyn), imipenem + cilastatin (Primaxin) . imipenem + cilastatin (Primaxin) .


BETALACTAM GROUPS

99

STRUKTUR DINDING GRAM (+) & GRAM (-)STRUKTUR DINDING GRAM (+) & GRAM (-)


- Amphotericin B- Amphotericin B

- Nystatin- Nystatin

- Colistin- Colistin

- Polymixin- Polymixin

Tidak digunakan untuk obat sistemik karena Tidak digunakan untuk obat sistemik karena toksiktoksik


::

- Chloramphenicol (50S)- Chloramphenicol (50S) - Aminoglycoside (30S) - Aminoglycoside (30S)- Erythromycin (50S) - Erythromycin (50S) - Tetracyclin (30S) - Tetracyclin (30S)- Lyncomycin (50S)- Lyncomycin (50S)

Ribosom Mamalia 80S, sedangkan bakteri 70S, reseptor Ribosom Mamalia 80S, sedangkan bakteri 70S, reseptor pada subunit 30S atau 50S.pada subunit 30S atau 50S.

MacrolidesMacrolides : erythromycin, roxithromycin, clarithromycin, : erythromycin, roxithromycin, clarithromycin, azithromycinazithromycin;; digunakan untuk bakteri Gdigunakan untuk bakteri Gramram (+) (+) ddan an beberapa bakteri Gbeberapa bakteri Gramram (-) (-)..

LincomycinLincomycin dandan ClindamycinClindamycin umumnya digunakan untuk bakteri Gram (+). (+).


AminoglycosideAminoglycoside : : Streptomycin, Streptomycin, kanamycin, tobramycin, and kanamycin, tobramycin, and amikacin.amikacin.

Most of Aminoglycoside are effective Most of Aminoglycoside are effective against against GGramram (+) (+) and and GGramram (-) (-) bacteria.bacteria.

Aminoglycoside Aminoglycoside ::bactericidalbactericidal,, others: others: bacteriostatibacteriostaticc


Selective antimicrobial action to a Selective antimicrobial action to a specific attack on the 70S ribosome of specific attack on the 70S ribosome of

bacteriabacteria Several medically important antibiotics owe their Several medically important antibiotics owe their

selective antimicrobial action to a specific attack selective antimicrobial action to a specific attack on the on the 70S ribosome of bacteria70S ribosome of bacteria, with , with mammalian mammalian 80S ribosomes80S ribosomes left unaffected. left unaffected.

Those that act on the 30S ribosome are:Those that act on the 30S ribosome are: AmikacinAmikacin GentamycinGentamycin KanamycinKanamycin NeomycinNeomycin StreptomycinStreptomycin TobramycinTobramycin


Antibiotics that act on the 50S Antibiotics that act on the 50S portion of the ribosome include:portion of the ribosome include:

ChloramphenicolChloramphenicol ClindamycinClindamycin FuradantinFuradantin Fusidic acidFusidic acid LincomycinLincomycin NitrofuranNitrofuran PuromycinPuromycin Quinopristin/DalfopristinQuinopristin/Dalfopristin SpectinomycinSpectinomycin TetracyclineTetracycline


Sulfonamide (berkompetisi dengan PABA)Sulfonamide (berkompetisi dengan PABA) Trimethoprim (menghambat Trimethoprim (menghambat dihidrofolic dihidrofolic

acid reduacid reducctasetase)) Rifampicin (Rifampicin (Streptomyces,Streptomyces, menghambat menghambat

enzenziim RNA polm RNA poliimerase, merase, mencegah mencegah sintessintesisis RNA) RNA)

Pyrimidine Pyrimidine Quinolone Quinolone : (blokade DNA gyrase): (blokade DNA gyrase)

- Nalidixic acid- Nalidixic acid - Cyprofloxacin- Cyprofloxacin

- - NorfloxacinNorfloxacin - Ofloxacin- Ofloxacin


QuinoloneQuinoloneFluoroquinolonesFluoroquinolones (synthetic (synthetic

chemicals) are broad spectrum and chemicals) are broad spectrum and examples include examples include norfloxacin, norfloxacin, ciprofloxacin, enoxacin, ciprofloxacin, enoxacin, levofloxacin, and trovafloxacinlevofloxacin, and trovafloxacin. .

The fluoroquinolones inhibiting one The fluoroquinolones inhibiting one or more of a group of enzymes or more of a group of enzymes called topoisomerase, enzymes called topoisomerase, enzymes needed for bacterial nucleic acid needed for bacterial nucleic acid synthesis. synthesis.


Inhibisi Pathway Folic Acid oleh Inhibisi Pathway Folic Acid oleh Sulfonamide danSulfonamide dan TrimethoprimTrimethoprim

SulfonaSulfonamide mide TrimethoprimTrimethoprim

Pteridine HPteridine H22

++ PurinePurine

P A B AP A B A FAH FAH22 FAHFAH4 + 4 + CC11

++ (Dihydro-(Dihydro- (Tetrahydro- (Tetrahydro- PyrimidinePyrimidine

Glutamic acidGlutamic acid folic ac folic acidid)) folic ac folic acidid))

Amino acidAmino acid

99


Antimicrobial SpectrumAntimicrobial SpectrumBROAD SPECTRUMBROAD SPECTRUM : Drugs that are effective : Drugs that are effective

against a variety of both gram-positive and against a variety of both gram-positive and gram-negative bacteria gram-negative bacteria (e.g., tetracycline, (e.g., tetracycline, streptomycin, cephalosporins, ampicillin, streptomycin, cephalosporins, ampicillin, sulfonamides).sulfonamides).

NARROW SPECTRUMNARROW SPECTRUM : Those effective : Those effective against just against just GGramram (+) (+) bacteria, just bacteria, just GGram ram (-)(-) bacteria, or only a few speciesbacteria, or only a few species (e.g., penicillin G, (e.g., penicillin G, erythromycin, clindamycin, gentamicin).erythromycin, clindamycin, gentamicin).


Range of Activity Organisms Affected Example Antibiotics

Narrow Spectrum

Gram-positives (Actinomyces, Corynebacteria, Bacillus, Clostridium, Pyogenic cocci, Spirochetes)

Macrolides (Erythromycin) Polypeptides (Polymyxin)

Moderate Spectrum

Gram-positives plus systemic, enteric and urinary tract Gram-negatives

Sulfonamides Aminoglycosides (Streptomycin, Gentamycin, Tobramycin)

Narrow/Moderate Spectrum

Gram-positives plus Gram-negatives

Beta-lactams (Penicillin, Ampicillin, Cephalosporins)

Broad SpectrumAll prokaryotes except Mycobacteria and Pseudomonas

Chloramphenicol Tetracycline

Anti-mycobacterial MycobacteriaIsoniazid EthambutolStreptomycin Rifampin


Antibacterial activity (spectrum) of antimicrobial agents.

Aerobicbacteria

Anaerobic bacteria

Spectrum Gram Gram Gram Gram

Examples(+) (-) (+) (-)

Broad + + + + cefoxitin, chloramphenicol, imipenam,

tetracyclinesIntermediat

e+ + + ± carbenicillin, ticarcillin, ceftiofur,

penicillin/clavulanic acid, cephalosporins

+ ± + ± ampicillin, amoxicillin

Narrow + aztreonam, polymyxin

+ ± + ± benzyl penicillin G

+ + aminoglycosides, spectinomycin, sulfonamides, trimethoprim

+ + enrofloxacin

+ + + lincosamides, macrolides,pleuromutilins,

vancomycin

+ + bacitracin

+ + nitroimidazoles± : variable activity

2121

Antimicrobial Effects on CellsAntimicrobial Effects on Cells Drugs that actually kill microorganisms are Drugs that actually kill microorganisms are

termed termed bactericidalbactericidal.. Drugs that only inhibit the growth of Drugs that only inhibit the growth of

microorganisms are termed microorganisms are termed bacteriostaticbacteriostatic..

The decision to use a bactericidal or The decision to use a bactericidal or bacteriostatic drug to treat infection bacteriostatic drug to treat infection depends entirely upon the type of depends entirely upon the type of infection. infection.

BBactericidactericid agent agents will kill cells that are s will kill cells that are actively growing. Bacteriostatics, will only actively growing. Bacteriostatics, will only inhibit the growth of cells; ultimate inhibit the growth of cells; ultimate elimination of the organisms is elimination of the organisms is dependent dependent upon host phagocytic activityupon host phagocytic activity. .


Bactericidal Bactericidal andand Bacteriostati BacteriostaticcSome antimicrobial agents are Some antimicrobial agents are cidalcidal

in action: they kill microorganisms in action: they kill microorganisms (e.g., (e.g., penicillins, cephalosporins, penicillins, cephalosporins, streptomycin, neomycinstreptomycin, neomycin). ).

Others are Others are static static in action: they in action: they inhibit microbial growth long enough inhibit microbial growth long enough for the body's own defenses to for the body's own defenses to remove the organisms (e.g., remove the organisms (e.g., tetracyclines, erythromycin, tetracyclines, erythromycin, sulfonamidessulfonamides). ).


Choice of AntimicrobialChoice of Antimicrobial A narrow spectrum is preferableA narrow spectrum is preferable since it will since it will

cause less destruction to the body's normal cause less destruction to the body's normal flora.flora.

Indiscriminate use of broad spectrum antibiotics Indiscriminate use of broad spectrum antibiotics can lead to superinfection by opportunistic can lead to superinfection by opportunistic microorganisms, such as microorganisms, such as CandidaCandida (yeast (yeast infections) and infections) and Clostridium difficileClostridium difficile (antibiotic- (antibiotic-associated ulcerative colitis), when the body's associated ulcerative colitis), when the body's normal flora is destroyed. normal flora is destroyed.

Other dangers from indiscriminate use of Other dangers from indiscriminate use of antimicrobial chemotherapeutic agents include antimicrobial chemotherapeutic agents include drug toxicity, allergic reactions to the drug, and drug toxicity, allergic reactions to the drug, and selection for resistant strains of microorganismsselection for resistant strains of microorganisms. . 2424dr. Edhie Djohan Utama, SpMK.dr. Edhie Djohan Utama, SpMK.

Site of Activity Example AntibioticsInhibition of cell wall integrity Lysozyme

Inhibition of cell wall synthesis :1. Biosynthetic enzymes (cytoplasmic)

Fosfomycin, Cycloserine

2. Membrane-bound phospholipid carrier

Bacitracin

3. Polymerization of subunits Beta-lactams

4. Combine with wall substrates Vancomycin

Inhibition of membrane integrity :

Surfactants, Polyenes, Polypeptides

Inhibition of membrane synthesis :

None

Inhibition of nucleic acid integrity :

Alkylating, Intercalating agents (mitomycin, chloroquin)

2525

Inhibition of nucleic acid synthesis :

1. Metabolism of DNA5-Fluorocytosine, Acyclovir, NTP analogs

2. Replication of DNANalidixic acid, Novobiocin, Nitroimadazoles

3. Synthesis of RNA Rifampin

Protein integrity : Phenolics, Heavy metals

Protein synthesis :

1. 30S SubunitStreptomycin, Kanamycin, Tetracycline

2. 50S SubunitChloramphenicol, Macrolides (Clindamycin, Erythromycin)

3. Folate metabolism Sulfonamides, Trimethoprim2626dr. Edhie Djohan Utama, SpMK.dr. Edhie Djohan Utama, SpMK.

Altered Receptors :1. Beta-lactams Altered Penicillin Binding Proteins

2. MacrolidesMethylation of 2 adenine residues in 23S RNA of the 50S subunit

3. RifampinSingle amino acid change in RNA polymerase ß-subunit

4. Sulfonamide/trimethoprimAltered synthetase binds pABA preferentially/altered reductase for TMP

5. Nalidixic acid Altered gyrase

6. Streptomycin Altered S12 protein in 30S subunit

Decreased Entry :1. Tetracycline Normally biphasic, active transport reduced

2. Fosfomycin (chromosomal) Glucose-6-phosphate transport reduced

Destruction/Inactivation :1. Chloramphenicol acetyltransferase Acetylates chloramphenicol

2. Beta-lactamase Cleaves ß-lactam ring

3. AminoglycosidesAcetylation or phosphorylation as drug passes membrane

2727

Side effects/Toxic effects Examples

Overgrowth of pathogensIntestinal (C. difficile), Vaginal (Candida)

Depression of intestinal symbiotes

Several

Nephrotoxicity Polypeptides, Aminoglycosides

Ototoxicity - 8th cranial nerve Aminoglycosides

Ophthalmic toxicity Ethambutol

Aplastic anemia Chloramphenicol

Hypersensitivity Penicillin

Bone seeking Tetracycline


CephalosporinsCephalosporins 1st 1st ggeneraenerationtion

2nd 2nd ggeneraenerationtion

3rd 3rd ggeneraenerationtion

4th 4th ggeneraenerationtion

Cefadroxil Cefaclor Cefdinir Cefepime

Cefazolin Cefamandole Cefoperaxone Cefpirom

Cefelixin Cefonicid Cefotaxime

Cephalothin Ceforanide Ceftazidime

Cephaprin Cefotetan Ceftibuten

Cephradine Cefoxitin Ceftizoxime

Cefuroxime Ceftriaxone

Cefixime

Cefdinir

Cefetamet2929

The Future of Chemotherapeutic The Future of Chemotherapeutic AgentsAgents

Many bacterial diseases, previously treatable with Many bacterial diseases, previously treatable with antibiotics, have become antibiotics, have become resistantresistant to antibiotics. to antibiotics.

Chemicals produced by plants and animals are Chemicals produced by plants and animals are providing providing new antimicrobial agentsnew antimicrobial agents, including , including antimicrobial peptides.antimicrobial peptides.

New antimicrobials include DNA that is New antimicrobials include DNA that is complementary to specific genes in a pathogen; complementary to specific genes in a pathogen; the DNA will bind to the pathogen's DNA or the DNA will bind to the pathogen's DNA or mRNA and inhibit protein synthesis.mRNA and inhibit protein synthesis.


Message From the Director Message From the Director General WHO (2000)General WHO (2000)

Drug resistance is the most telling sign that Drug resistance is the most telling sign that we have failed to take the treat of infectious we have failed to take the treat of infectious diseases seriodiseases seriouusly. It suggests that we have sly. It suggests that we have mishandled of disease fighting drugs, by mishandled of disease fighting drugs, by misusing, underusing and overusing them.misusing, underusing and overusing them.

““A World without Antibiotics”. It could bring A World without Antibiotics”. It could bring back to a pre-antibiotic age. We are back to a pre-antibiotic age. We are vulnerable without effective medicines.vulnerable without effective medicines.


Impact of Resistance :

1940's Staph aureus 99% sensitive to penicillin G and all other Beta lactam antibiotics.

1970's Staph aureus 75% resistant to penicillin and ampicillin but still 99% sensitive to flucloxacillin and cephalosporin.

1990's

Staph aureus 98% resistant to penicillin and 20% resistant to flucloxacillin and all Beta lactams. Vancomycin and Teicoplanin only therapeutic options remaining.

1995 -1996

Intensive care units - Acinetobacter and Moraxella species resistant to all antibiotics tested. 3232

MICROBIAL RESISTANCE TO MICROBIAL RESISTANCE TO ANTIMICROBIAL ANTIMICROBIAL

CHEMOTHERAPEUTIC AGENTSCHEMOTHERAPEUTIC AGENTS

A common problem in A common problem in antimicrobial chemotherapy is antimicrobial chemotherapy is the the development of resistant strains of development of resistant strains of bacteriabacteria. Most bacteria become . Most bacteria become resistant to antimicrobial agents resistant to antimicrobial agents by one or more of the following by one or more of the following mechanisms: mechanisms:


Mekanisme terjadinya strainMekanisme terjadinya strain resistresisteenn

1. 1. Producing enzymes which detoxify or Producing enzymes which detoxify or inactivate the antibioticinactivate the antibiotic, e.g., , e.g., penicillinase and other beta-lactamases. penicillinase and other beta-lactamases.

2. 2. Altering the target site in the Altering the target site in the bacterium to reduce or block binding bacterium to reduce or block binding of the antibioticof the antibiotic, e.g., producing a , e.g., producing a slightly altered ribosomal subunit that still slightly altered ribosomal subunit that still functions but to which the drug can't bind. functions but to which the drug can't bind.

3. 3. Preventing transport of the Preventing transport of the antimicrobial agent into the antimicrobial agent into the bacteriumbacterium, eg., producing an altered , eg., producing an altered cytoplasmic membrane or outer cytoplasmic membrane or outer membrane. membrane.


4. 4. Developing an alternate metabolic Developing an alternate metabolic pathway to by-pass the metabolic pathway to by-pass the metabolic step being blocked by the step being blocked by the antimicrobial agentantimicrobial agent, e.g., overcoming , e.g., overcoming drugs that resemble substrates and tie-up drugs that resemble substrates and tie-up bacterial enzymes. bacterial enzymes.

5. 5. Increasing the production of a Increasing the production of a certain bacterial enzymecertain bacterial enzyme, e.g., , e.g., overcoming drugs that resemble overcoming drugs that resemble substrates and tie-up bacterial enzymes. substrates and tie-up bacterial enzymes.

dr. Edhie Djohan Utama, SpMK.dr. Edhie Djohan Utama, SpMK. 3535

UJI KEPEKAAN BAKTERI UJI KEPEKAAN BAKTERI TERHADAP ANTIMIKROBATERHADAP ANTIMIKROBA

CARA PENGENCERANCARA PENGENCERAN (Dilution (Dilution Methods) :Methods) :Memakai media cairMemakai media cairMemakai media padatMemakai media padat

Cara ini kwantitatip dan Cara ini kwantitatip dan akuratakurat

CARA DIFUSICARA DIFUSI (Diffusion Methods) : (Diffusion Methods) :Memakai cakram antimikrobaMemakai cakram antimikrobaTablet antimikrobaTablet antimikroba

Cara ini kwalitatip dan rutin Cara ini kwalitatip dan rutin dilakukan dilakukan 3636dr. Edhie Djohan Utama, SpMK.dr. Edhie Djohan Utama, SpMK.

CARA PENGENCERANCARA PENGENCERAN

KWANTITATIPKWANTITATIPKHM (Kadar Hambatan Minimal = MIC)KHM (Kadar Hambatan Minimal = MIC)KBM (Kadar BKBM (Kadar Bunuhunuh Minimal = MBC) Minimal = MBC)

AKURATAKURAT

UNTUK PENELITIAN / PERMINTAAN KHUSUSUNTUK PENELITIAN / PERMINTAAN KHUSUS


CARA PENGENCERAN (lanjutan)CARA PENGENCERAN (lanjutan)MEDIA CAIRMEDIA CAIR

Cara MakroCara Makro : seri 12 tabung reaksi : seri 12 tabung reaksiCara Mikro : platCara Mikro : plat m mikrotiter, pipetikrotiter, pipet mikro mikro

MEDIA PADATMEDIA PADATMueller Hinton Agar

AM diencerkan kelipatan dua (1 ug, 0,5 ug, AM diencerkan kelipatan dua (1 ug, 0,5 ug,

0.25 ug. 0.125 ug, dst)0.25 ug. 0.125 ug, dst)

Larutan bakteri log phase MacFarland 1Larutan bakteri log phase MacFarland 1


CARA DIFUSICARA DIFUSI MEDIA :MEDIA :

Mueller Hinton Agar atau Mueller Hinton Agar atau Sensitest AgarSensitest Agar

Jika bakteri fastidiJika bakteri fastidiuus : Agar Darahs : Agar Darah BAKTERI :BAKTERI :

Bakteri Log phase, kelarutan MacFarland 0,5Bakteri Log phase, kelarutan MacFarland 0,5Disemaikan dengan kapas lidi steril 3 streakDisemaikan dengan kapas lidi steril 3 streak

CAKRAM :CAKRAM :Kertas saringKertas saringTabletTablet


MEMBACA DAERAH INHIBISIMEMBACA DAERAH INHIBISI Daerah inhibisi diukur Daerah inhibisi diukur

menggunakanmenggunakan kkaliper aliper (jangka sorong) atau (jangka sorong) atau penggarispenggaris

Lebar daerah inhibisi Lebar daerah inhibisi disesuaikan dengan daftar disesuaikan dengan daftar dari setiap AM dan Bakteri dari setiap AM dan Bakteri yang diuji kepekaannya yang diuji kepekaannya (setelah dieramkan 18-24 (setelah dieramkan 18-24 jam).jam).

DinyatakanDinyatakan:: SensitiSensitif (f (ssusceptibleusceptible),), Hampir resistenHampir resisten,, ResistenResisten


ANTIMIKROBA

GENUS

Kandungan disk (cakram

AM)

Diameter Zona Hambat (mm)

Resisten Intermediat Sensitif

β-LACTAMS

Ampicillin Enterobacteriaceae 10 µg <13 14-16 >17

Staphylococci 10 µg <28 >29

Enterococci 10 µg <16 >17

Carbenicillin Pseudomonas 100 µg <13 14-16 >16

Gram (-) 100 µg <19 20-22 >23

Methicillin Staphylococci 5 µg <9 13-Oct >14

Mezlocillin Pseudomonas 75 µg <15 >16

Other Gram (-) 75 µg <17 18-20 >21

Nafcillin Staphylococci 1 µg <10 12-Nov >13

Oxacillin Staphylococci 1 µg <10 12-Nov >13

Penicillin Staphylococci 10 units <28 >29

Enterococci 10 units <14 >15

Piperacillin Pseudomonas 100 µg <17 >18

Other Gram (-) 100 µg <17 18-20 >21 4141dr. Edhie Djohan Utama, SpMK.dr. Edhie Djohan Utama, SpMK.

FAKTOR PENYEBAB RESISTENSIFAKTOR PENYEBAB RESISTENSIFaktor non genetik :Faktor non genetik :

AM akan resisten jika bukan pada masa aktif pembelahan bakteri. Pada umumnya Pada umumnya semua AM baru bisa bekerja baik pada semua AM baru bisa bekerja baik pada masa aktimasa aktiff pembelahan bakteri. pembelahan bakteri.

Hilangnya struktur target untuk AM Hilangnya struktur target untuk AM (kehilangan dinding sel)(kehilangan dinding sel),, sehingga obat sehingga obat betalaktam jadi resisten. betalaktam jadi resisten.

Faktor genetik :Faktor genetik : Terjadi perTerjadi peruubahan genetik bahan genetik menimbulkan resistensi bakteri.menimbulkan resistensi bakteri. Resistensi kromosomal Resistensi ekstrakromosomal (melalui

Plasmid)4242

CARA TERJADINYA RESISTENSICARA TERJADINYA RESISTENSI INTRINSICINTRINSIC ::

Hal ini biasa untuk semua speHal ini biasa untuk semua spessies dimana speies dimana spessies ies tertentu tidak mempunyai target atau reseptor untuk tertentu tidak mempunyai target atau reseptor untuk antimikroba, atau ada barrier alamiah a.l.:antimikroba, atau ada barrier alamiah a.l.:

= Bakteri anaerob terhadap Aminogl= Bakteri anaerob terhadap Aminoglikikosidosidaa

= Streptococcus resisten terhadap Aminogl= Streptococcus resisten terhadap Aminoglikikosidosidaa karena karena

mempunyai /adanya barier alamiah.mempunyai /adanya barier alamiah.

= Enterobacteriaceae resisten terhadap PNC-G= Enterobacteriaceae resisten terhadap PNC-G ACQUIREDACQUIRED : FAKTOR EKSTRA KHROMOSOMAL : FAKTOR EKSTRA KHROMOSOMAL

Modifikasi genetik karena mutasi, tranfer gene melalui Modifikasi genetik karena mutasi, tranfer gene melalui transfer Plasmid (transformasi, transduksi, konyugasi) sebab Plasmid membawa R Factor atau transposon 4343dr. Edhie Djohan Utama, SpMK.dr. Edhie Djohan Utama, SpMK.

PLASMIDPLASMID Plasmid Plasmid == closed loop of DNAclosed loop of DNA, , elemen elemen genetigenetik yg sangat k yg sangat

kecilkecil (berat kira2 1-3% kromosom bakteri) (berat kira2 1-3% kromosom bakteri), , didi luar luar kkromosom, membawa gen resisten terhadap antimikroba.romosom, membawa gen resisten terhadap antimikroba.

MMampu ampu bebereplikasi direplikasi di dalam dalam ssel bakteri secara autonomel bakteri secara autonom

Bisa berpindah Bisa berpindah antarantar spe spessies (broad host range) ies (broad host range)

Berada bebas dalam sitoplasma bakteriBerada bebas dalam sitoplasma bakteri

Salah satu Plasmid adalah Salah satu Plasmid adalah R FactorR Factor, beberapa , beberapa R Factor R Factor membawa transposon membawa transposon (gen resisten yang bisa berpindah dari satu Plasmid ke Plasmid lainnya atau ke kromosom).

Kini dikenal lagi INTEGRON

Contoh lain : toksin bakteri dan faktorContoh lain : toksin bakteri dan faktor F (fertility)F (fertility). .


CARA PERPINDAHAN GENCARA PERPINDAHAN GEN TRANSDUKSITRANSDUKSI

Plasmid DNA via BaPlasmid DNA via Bakkterioterioffagagaa (biasa bakteri Gam (biasa bakteri Gam positip) ditransfer ke populasi kuman lain.positip) ditransfer ke populasi kuman lain.

TRANSFORMASITRANSFORMASI (fragment DNA bebas dapat (fragment DNA bebas dapat melewati dinding melewati dinding ssel dan kemudian bersatu dalam el dan kemudian bersatu dalam genom sel)genom sel).. Biasa dilakukan di laboratorium (rekayasa Biasa dilakukan di laboratorium (rekayasa genetik)genetik).. Pindah secara spontanPindah secara spontan

KONYUGASIKONYUGASIMelalui Melalui Fertility Factor Fertility Factor maka RTF (Resistmaka RTF (Resistaanntt Transfer Transfer Factor) pindah dari Factor) pindah dari satu satu sel ke sel lain sering sel ke sel lain sering menyebabkan menyebabkan multidrug resistenmultidrug resisten..

TRANSLOKASI / TRANSPOSISITRANSLOKASI / TRANSPOSISIPerpindahan bagian Perpindahan bagian kkromosom dalam sel romosom dalam sel


CONJUGATIVE TRANSPOSONCONJUGATIVE TRANSPOSON

Telah dikenal type baru elemen conjugative yaitu Telah dikenal type baru elemen conjugative yaitu Conjugative TransposonConjugative Transposon

Terdapat didalam khromosom bakteri.Terdapat didalam khromosom bakteri. Conjugative Transposon terintegrasi didalam Plasmid Conjugative Transposon terintegrasi didalam Plasmid

atau berada di dalam khromosom bakteri sehingga atau berada di dalam khromosom bakteri sehingga lebih susah untuk dideteksi.lebih susah untuk dideteksi.

Ada kemungkinan bertanggung jawab dalam Ada kemungkinan bertanggung jawab dalam kebanyakan transfer Plasmid kebanyakan transfer Plasmid

Transfer terjadi tidak hanya antar species pada group Transfer terjadi tidak hanya antar species pada group Bakteri Gram(+) atau antar group Bakteri Gram (-) Bakteri Gram(+) atau antar group Bakteri Gram (-) tetapi juga antara Bakteri Gram (+) dan Bakteri Gram tetapi juga antara Bakteri Gram (+) dan Bakteri Gram (-)(-)

Transposons or "jumping genes" are capable of integration into the chromosome of a bacteria or into plasmids. The can be a whole gene or part of a gene.


INTEGRONINTEGRONKINI DIKENAL ELEMENT INTERGRATING KINI DIKENAL ELEMENT INTERGRATING

BARU = INTEGRONBARU = INTEGRON

INTEGRON BERTANGGUNG JAWAB UN-INTEGRON BERTANGGUNG JAWAB UN-TUK BERBAGAI PLSMID YANG MEMBA-TUK BERBAGAI PLSMID YANG MEMBA-WA WA MULTIPLE DRUG RESISTANCE GENEMULTIPLE DRUG RESISTANCE GENE

INTEGRON SEPERTI TRANSPOSON INTEGRON SEPERTI TRANSPOSON ADALAH SEGMEN DNA LINEAR.ADALAH SEGMEN DNA LINEAR.


RESISTENSI PADA BETALAKTAM :RESISTENSI PADA BETALAKTAM :

EnzEnziim m ββ-laktamase yang dihasilkan bakteri membuka -laktamase yang dihasilkan bakteri membuka (cleaves) cincin (cleaves) cincin ββ-laktam sehingga -laktam sehingga tdk tdk aktiaktiff. Bakteri . Bakteri Gram(-) menghasilkan Gram(-) menghasilkan ββ-la-lakktamase dalam periplasma tamase dalam periplasma sedangkan bakteri Gram(+) sedangkan bakteri Gram(+) : : dalam cairan ekstraseluldalam cairan ekstraselulaar.r.

Tidak adanya PBP (Penicillin Binding Protein) reseptor Tidak adanya PBP (Penicillin Binding Protein) reseptor bakteri menjadi resisten. (Alteration of the target of bakteri menjadi resisten. (Alteration of the target of the antibiotic) Dalam hal ini penambahan the antibiotic) Dalam hal ini penambahan ββ--laktamase laktamase inhibitor tidak berguna.inhibitor tidak berguna.


RESISTENSI PADA RESISTENSI PADA BETALAKTAM :BETALAKTAM :

Betalaktam tidak berhasil mengaktivasi Betalaktam tidak berhasil mengaktivasi autolytic enzyme autolytic enzyme ((yang menghancurkan yang menghancurkan peptidoglpeptidoglikikan), sehingga bakteri menjadi an), sehingga bakteri menjadi toleran.toleran.

Resisten terhadap AM Glycopeptide : walau Resisten terhadap AM Glycopeptide : walau belum jelas benar, tetapi 2 gene (vanA & belum jelas benar, tetapi 2 gene (vanA & vanH) yang terlibat menye-babkan dihasilkan vanH) yang terlibat menye-babkan dihasilkan protein yang berbeda yang tidak mengi-kat protein yang berbeda yang tidak mengi-kat Vancomycin.Vancomycin.

dr. Edhie Djohan Utama, SpMK.dr. Edhie Djohan Utama, SpMK. 5050

ANTI ENZYME BETALACTAMASEANTI ENZYME BETALACTAMASEObat gol. betalaktam Obat gol. betalaktam menjadi resisten karena bakteri menghasilkan enzim betalaktamase yang yang menghancurkan cincin beta-laktam dari obat.menghancurkan cincin beta-laktam dari obat.

EnzEnziim betalaktamase tersebut bisa dirusak dengan m betalaktamase tersebut bisa dirusak dengan menambahkan salah satu zat di bawah ini :menambahkan salah satu zat di bawah ini :

+ Clavulanic acid (Augmentin)+ Clavulanic acid (Augmentin)

+ Sulbactam (Sulperazon)+ Sulbactam (Sulperazon)

+ Tazobactam + Tazobactam (Piperacillin + Tazobactam)(Piperacillin + Tazobactam)

Penambahan salah satu zat diatas menyebabkan obat Penambahan salah satu zat diatas menyebabkan obat golongan betalaktam golongan betalaktam menjadi sensitimenjadi sensitiff kembali kembali..


MRSAMRSA,, VISA VISA,, VRSA VRSA,, ESBLs ESBLs MRSA : MethMRSA : Methiicillincillin-r-resistant esistant S. S. aaureusureus

MRSA refers to a type of bacteria MRSA refers to a type of bacteria ((Staphylococcus aureusStaphylococcus aureus) that is resistant to ) that is resistant to many antibiotics. It is a common cause of many antibiotics. It is a common cause of hospitalhospital--acquired infections.acquired infections.

MupirocinMupirocin ointment has also shown promising ointment has also shown promising results in decreasing nasal carriage. Wide results in decreasing nasal carriage. Wide spread use is only indicated in certain settings spread use is only indicated in certain settings to avoid mupirocin resistance. to avoid mupirocin resistance.

VISA : Vancomycin IntermVISA : Vancomycin Intermeediate diate S. S. aaureusureus

VRSA : Vancomycin Resistant VRSA : Vancomycin Resistant S. S. aaureusureus 5252dr. Edhie Djohan Utama, SpMK.dr. Edhie Djohan Utama, SpMK.

ESBL = Extended spectrum beta lactamase. ESBL = Extended spectrum beta lactamase. This term refers to This term refers to beta lactamase enzymesbeta lactamase enzymes produced mainly by produced mainly by KlebsiellaKlebsiella and and E. coliE. coli that encode for resistance to broad-that encode for resistance to broad-spectrum spectrum ββ-lactam antibiotics that -lactam antibiotics that normally have activity against Gramnormally have activity against Gram (-) (-) bacilli. bacilli.

Examples are cefotaxime, ceftriaxone, Examples are cefotaxime, ceftriaxone, ceftazidime, aztreonam and cefpodoxime. ceftazidime, aztreonam and cefpodoxime.

These enzymes are These enzymes are not active againstnot active against the the cephamycins, and are inhibited by cephamycins, and are inhibited by clavulanic acid.clavulanic acid.


AMINOGLAMINOGLIKIKOSIDOSIDAA BaBakkteriterissidal, inaidal, inakktitiff pd pH rendah dan pd pH rendah dan

anaerob dan MO intraanaerob dan MO intrasselularelular SSiinergistik dengan grupnergistik dengan grup Beta-laBeta-lakktamtam Ampuh untuk bakteri Batang Gram Ampuh untuk bakteri Batang Gram (-)(-) ToToksksiikk pada dosis tinggi pada dosis tinggi Menghambat sintesMenghambat sintesisis protein dengan protein dengan

berberikatan pada 30S ribosomal unit sehingga ikatan pada 30S ribosomal unit sehingga tjd tjd misreadingmisreading mRNA mRNA

Streptomycin, Kanamycin, Gentamycin, Streptomycin, Kanamycin, Gentamycin, Tobramycin, Amikacin, NetilmicinTobramycin, Amikacin, Netilmicin


RESISTENSI PADA AMINOGLRESISTENSI PADA AMINOGLIKIKOSIDOSIDAA

Reseptor subunit 30 S hilangReseptor subunit 30 S hilangTerdapat enzTerdapat enziim yang m yang

menghancurkan obat (acethylase, menghancurkan obat (acethylase, adenylase dan fosforilase)adenylase dan fosforilase)

Permeabilitas terhadap obat turun, Permeabilitas terhadap obat turun, transport obat ketransport obat ke dalam dalam ssel el berkurangberkurang sehingga tidak mencapai sehingga tidak mencapai RibosomRibosom


IMPLIKASI KLINIS RESISTENSIIMPLIKASI KLINIS RESISTENSI Timbulnya resistensi bakteri terhadap Timbulnya resistensi bakteri terhadap

antimikroba bahkan terjadinya multiple antimikroba bahkan terjadinya multiple drugs resisten drugs resisten (MDR)(MDR) bisa mengundang bisa mengundang banyak problem berat dalam pengobatan banyak problem berat dalam pengobatan penyakit infeksipenyakit infeksi

Timbulnya Timbulnya “Kuman Rumah Sakit”“Kuman Rumah Sakit” yang amat yang amat resisten sebab RS sering menggunakan resisten sebab RS sering menggunakan dosis tinggi dan dalam intensitas tinggi.dosis tinggi dan dalam intensitas tinggi.

Antibiotik baru perlu riset yg lama (10-20 Antibiotik baru perlu riset yg lama (10-20 tahun) sehingga bisa terjadi tahun) sehingga bisa terjadi tiadanya tiadanya antibiotikaantibiotika yang bisa digunakan untuk yang bisa digunakan untuk mengobati penyakit infeksi.mengobati penyakit infeksi.


Prevention and control of antibiotic resistance

Reduce selective pressures: 1. Use antibiotics for bacterial disease 2. Use appropriate dosing and length of time 3. Change medication if ineffective4. Use appropriate medication for a specific site5. Stop use of antibiotics in the animal husbandry for growth promotion6. Regulate prescribing practices in veterinary medicine 7. Establish antibiotic prescribing practices and distribution especially in countries that allow over the counter medications without precripton 8. Educate the public to the dangers of overuse/misuse of antibiotics


Antifungal Drugs1.Polyenes, such as nystatin and amphotericin B,

combine with plasma membrane sterols and are fungicidal.

2. Azoles interfere with sterol synthesis and are used to treat cutaneous and systemic mycoses.

3. Griseofulvin interferes with eukaryotic cell division and is used primarily to treat skin infections caused by fungi.


Antifungals that bind sterols :Membrane structural differences :

The composition of the fungal plasma membrane differs from the composition of the mammalian plasma membrane particular in terms of the presence or absence of certain kinds of sterols.

There exist antibiotics that, consequently, more effectively recognize fungal plasma membrane than mammalian plasma membrane.

Examples include:= amphotericin B = nystatin = ketoconazole = miconazole


AntiviralAntiviral DrugsDrugs

1. 1. AmantadineAmantadine blocks penetration or uncoating of blocks penetration or uncoating of influenza A virusinfluenza A virus..

2. 2. Nucleoside and nucleotide analogsNucleoside and nucleotide analogs such as such as acycloviracyclovir, , AZTAZT, , ddIddI, and , and ddC inhibit DNA or RNA synthesisddC inhibit DNA or RNA synthesis..

3. 3. Protease inhibitorsProtease inhibitors, such as , such as indinavirindinavir and and saquinavirsaquinavir, , blockblock activity of an HIV enzyme essential for activity of an HIV enzyme essential for assembly of assembly of a new viral coata new viral coat..

4. 4. Alpha-interferonsAlpha-interferons inhibit the spread of viruses to new inhibit the spread of viruses to new cells.cells.


k.9 Resistensi Antimikroba1

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