Form Gyssens

This document provides categories and descriptions for qualitative analysis of antimicrobial usage at an ICU based on the Gyssens method. It includes definitions for types of antimicrobial therapy like empiric, documented, or prophylaxis. The analysis evaluates appropriateness of antimicrobial use based on factors like dosage, duration, and alternative treatment options. Culture results and patient vital signs and lab results are also documented for review.

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Sitti Jumriah Maurana

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Form Gyssens

Uploaded by

Sitti Jumriah Maurana

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RESUME OF ANTIMICROBIAL USAGE INFORMATION AND CATEGORIZATION

Type of therapy :
ADE = Antimicrobial Drug Empiric therapy, ADET = Antimicrobial Drug Extended Empiric Therapy,Aa = Alternative agent,ADD = Antimicrobial Drug Documented therapy, ADP = Antimcrobial Drug P

NOTE :TIDAK BOLEH MERUBAH KOLOM

ADE = Antimicrobial Drug Empiric therapy, ADET = Antimicrobial Drug Extended Empiric Therapy,Aa = Alternative agent,ADD = Antimicrobial Drug
Documented therapy, ADP = Antimcrobial Drug Prophylaxis, ADU = Antimicrobial Drug Unknown therapy
ANALISA KUALITATIF PENGGUNAAN ANTIBIOTIK DENGAN METODE GYSSENS PASIEN ICU RSUD Dr. MOEWARDI
PERIODE : SEPTEMBER 2019
1 No RM : 0145xxx Masuk RS : 25/8/2019 (09.34) Reviewer :
No reg : Masuk ICU :
Nama Pasien : Tn. S Keluar ICU :
Tanggal lahir : Keluar RS : 5/9/2019 (15.54)
Diagnosa : OA Genu S grade IV post TKR
A. Data penggunaan antibiotik/Metode Gyssens

Type of Unit Dose Start Stop Duration Total 0 I II III

Generic Freq (X) Route
therapy (mg) d/m/y d/m/y (day) (day)
A B C A
ADP Netilmycin 2x300 mg 2x300 mg IV 2/9/2019 2/9/2019 1 1 v
ADE Netilmycin 2x300 mg 2x300 mg IV 2/9/2019 4/9/2019 3 3 v
AD
Aa
AD … 0 0
Aa
AD … 0 0
Aa
AD … 0 0
Aa
AD … 0 0
Aa
B. Hasil kultur
Tanggal Spesimen Bakteri Antibiotik Sensitif Antibiotik Intermediate

C. Tanda-tanda vital D. Hasil laboratorium

Tanggal 6/9/1 7/9/1 8/9/1 9/9/19 Parameter
Tek. Darah 130/ 120/ 125/ 120/80 Leukosit (x10³/uL)
Suhu 36,7 37,2 36,9 37
Nadi 80 82 79 80
RR 18 16 22 18
E. Evaluasi
Diagnosa Organisme penyebab yang utama Antibiotik Dosis Antibiotik
OA Genu S grade IV post TKR Netilmicin OD : 6,5 mg per kg q24h Sanford Guid

nt,ADD = Antimicrobial Drug Documented therapy, ADP = Antimcrobial Drug Prophylaxis, ADU = Antimicrobial Drug Unknown therapy

III IV V VI
B A B C D

v v V

Antibiotik Resisten

Literatur
Sanford Guidline

Kategori Deskripsi Jumlah %

0 Pengobatan sudah tepat
1 Tidak tepat saat pemberian Antibiotik (profilaksis)
2 A TIdak tepat dosis
B Tidak tepat interval
C Tidak tepat cara pemberian
3 A Tidak tepat karena terlalu lama
B Tidak tepat karena terlalu singkat
4 A Tidak tepat, ada obat lain yang lebih efektif
B Tidak tepat, ada yang kurang toksik/lebih aman
C Tidak tepat, ada yang lebih murah
D Tidak tepat, ada yang lebih spesifik
5 Tidak ada indikasi
6 Rekam medic tidak lengkap untuk dievaluasi
Total
RESUME OF ANTIMICROBIAL USAGE INFORMATION AND CATEGORIZATION
Type of therapy :
ADE = Antimicrobial Drug Empiric therapy, ADET = Antimicrobial Drug Extended Empiric Therapy, Aa = Alternative agent
ADD = Antimicrobial Drug Documented therapy, ADP = Antimcrobial Drug Prophylaxis, ADU = Antimicrobial Drug Unknow therapy,

1 No reg :
Nama PX :
No RM :
Diagnosa :

A. Tanda-tanda vital
Tanggal
Tek. Darah
Suhu
Nadi
Respirasi

B. Gyssens
Unit Freq Start Stop Duration Total
Type of I II III
Generic Dose (x) Route d/m/y d/m/y (day) day
therapy
(mg) A B C A B
AD … 0 0
Aa
AD … 0 0
Aa
AD… 0 0
Aa
AD… 0 0
Aa
AD… 0 0

C. Evaluasi
Diagnosa Bakteri Antibiotik Keterangan
herapy,

IV V VI
A B C D