Analisis Farmakoekonomi Penggunaan Antibiotika Pada Pasien Pneumonia Rawat Inap Di Rumah Sakit Umum Pusat Haji Adam Malik

Lampiran 1. Surat Persetujuan Telah Menyelesaikan Penelitian

53
Universitas Sumatera Utara

Lampiran 2 Surat Ethical Clearence

54
Universitas Sumatera Utara

Lampiran 3 Data Demografi Pasien Pneumonia RSUP H.Adam Malik

No

Model Terapi

Ciprofloksasin (Infus)
1 + Ceftriakson (Injeksi)

Eritromisin(oral) +
2 Ceftriakson (injeksi)

Cefotaxim(injeksi) +
3 Gentamisin (injeksi)

No
Rekam
Medik

Tgl Keluar

Status

Lama
Rawat
inap

Penurunan
WBC
(mm3)

4-Jan-13
15-Jun-13
10-Jan-12
21-Jun-13
12-Mei-12
1-okt-13
11-Jul-12
29-des-12
30-des-12
9-Mar-13
24-Nov-12
5-Sep-12

11-Jan-13
23-Jun-13
15-Jan-12
27-Jun-13
18-Mei-12
7-okt-13
18-Jul-12

2-Jan-13
5-Jan-13
18-Mar-13
29-Nov-12
12-Sep-12

Pbj
Pbj
Pbj
Pbj
Pbj
Pbj
Pbj
Pbj
Pbj
Pbj
Pbj
Pbj

7

8
5
6
6
7
7
4
6
9
5
7

1.32
1.42
1.36
1.11
1.51
0.99
1.14
1.05

0.96
1.19
1.05
1.21

Lk
Pr
Pr

25-Feb-12
25-Feb-13
3-Feb-13

3-Mar-12
2-Feb-13
8-Feb-13

Pbj
Pbj
Pbj

6
5
5

1.52
2.24
2.46

Lk
Lk

3-mei-12
21-Jun-12

13-mei-12
29-Jun-12

Pbj
pbj

10
8

1.2
1.93

Jenis
Tgl Masuk
Kelamin

Nama

Usia

54.32.30
56.30.80
54.40.74
51.87.69
50.13.20

57.65.81
48.65.45
58.59.47
57.66.82
55.09.53
53.89.43
52.90.85

AD
IY
TH
DG
MY
ZH
KH
BZ
AT
LH
DM
TR

65
53
64
47
65
40
53
58
23
45
34
44

Lk
Pr
Pr
Pr
Lk
Lk

Lk
Lk
Pr
Lk
Lk
Lk

54.94.23
54.38.76
54.45.10

MH
ST
SF

71
48
57

52.72.67

53.53.56

IW
SL

63
48

55
Universitas Sumatera Utara

Ceftriakson(Injeksi) +
4 Ciprofloksasin (oral)

5 Ceftriakson(inj)

Ceftrikson(Injeksi) +
6 Gentamisin (Injeksi)

Ceftazidin (injeksi) +
7 Ciprofloksasin(Injeksi)

56.05.37
51.60.03
55.72.67

RS
SB
MI

12
68
45

Pr
Lk
Pr

24-mei-12
23-mei-13
28-Apr-13

29-mei-12
3-mei-13
8-mei-13

Pbj
Pbj
Pbj

5
10
10

1.39
2.05
1.73

54.00.36
56.36.07
50.06.60
54.55.80
56.73.65
50.82.45
52.63.75
53.46.94

BH
IG
JD
AS
RT
ZB
AR
PN

62
45
49
48
50
39
53
44

Pr
Lk
Lk
Pr
Lk
Lk
Lk
Pr

23-Jan-13
19-Jun-13
27-Jul-13
22-Jan-12
16-Jul-13
19-Mar-13
8-agt-13
22-okt-13

29-Jan-13
27-Jun-13
2-Agt-13
31-Jan-12
28-Jul-13
24-Mar
13-agt-13
30-okt-13

Pbj
Pbj
Pbj
Pbj
Pbj
Pbj
Pbj
Pbj

6
8
6
9
12
5
5
8

0.68
1.03
0.36
2.13
1.79
2.91
2.03
2.04

56.69.89
54.98.98
58.59.71
52.27.65
49.99.23
57.75.92
52.87.16
56.66.79
54.84.15

RN
PP
KP
ES
AL
FH
GP
ES
SP

37
69
54
63
57
74
41
62
65

Lk
Pr
Pr
Pr
Pr
Lk
Lk
Pr
Lk

11-Jul-13
28-Jan-13
25-des-13
11-Jul-13
26-Jan-13
10-okt-13
31-okt-13
10-Jul-13
15-Feb-13

18-Jul-13
6-Feb-13
29-des-13
21-Jul-13
2-Feb-13
16-okt-13
10-Nov-13
16-Jul-13
22-Feb-13

Pbj
Pbj
Pbj
Pbj
Pbj
Pbj
Pbj
Pbj
Pbj

7
6
4
9
7
6
10
6
7

3.07
3.3
3.6
2.1
2.4
2.69
1.03
2.1
2.2

56.85.28
57.76.97

HS
RS

44
39

Lk
Lk

25-Jul-13
11-Okt-13

7-agt-13
16-okt-13

Pbj
Pbj

12
5

0.76
1.57

56
Universitas Sumatera Utara

Ampisilin (Injeksi) +
8 Gentamisin (injeksi)

Ceftriakson (injeksi) +
9 Cefadroksil (oral)

49.59.18
41.65.96
50.99.99

NH
KL
RS

47
56
39

Lk
Lk
Lk

9-Jan-12
15-Feb-12
1-Apr-12

17-Jan-12
19-Feb-12
5-Apr-12

Pbj
Pbj
Pbj

8
4
4

0.83
1.68
0.99

58.21.45
58.54.30
54.84.78

SM
MR
AL

11 (bln)
1 (bln)
5 (bln)

Lk
Lk
Lk

20-Nov-13
23-des-13
16-Feb-13

24-Nov-13
27-des-13
22-Feb-13

Pbj
Pbj
Pbj

4
4
6

2.24
1.08
0.95

56.41.84
54.84.97
57.51.85

RH
BS
RS

71
51
75

Pr
Pr
Lk

24-Jun-12
16-Feb-12
21-Sep-13

1-Jul-13
21-Feb-12
30-Sep-13

Pbj
Pbj
Pbj

7
6
9

1.69
1.14
1.81

57
Universitas Sumatera Utara

Lampiran 4 Biaya Rawat Inap Pasien Pneumonia RSUP H. Adam Malik
No Rekam Medik

Lama Rawat inap

Kelas Rawat inap

Biaya Per hari Rawat Inap
(Rp)

54.32.30
56.30.80
54.40.74
51.87.69
50.13.20
57.65.81
48.65.45
58.59.47
57.66.82
55.09.53
53.89.43
52.90.85
54.94.23
54.38.76
54.45.10
52.72.67
56.05.37
51.60.03
55.72.67
54.00.36

7
8
5
6
6
7
7
4
6
9
5
7
6
5
5
10
5
10
10
6

III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III

45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000

Biaya Total Rawat
Inap (Rp)
315000
360000
225000
270000
270000
315000
315000
180000
270000
405000
225000
315000
270000
225000
225000
450000
225000
450000
450000
270000

58
Universitas Sumatera Utara

56.36.07
50.06.60
54.55.80
56.73.65
50.82.45
51.06.82
52.63.75
53.46.94
56.69.89
54.98.98
58.59.71
52.27.65
49.99.23
57.75.92
52.87.16
56.66.79
54.84.15
56.85.28
57.76.97
49.59.18
41.65.96
50.99.99
58.21.45
58.54.30

8
6
9
12
5
6
5
8
7
6
4
9
7
6
10
6
7
12
5
8
4
4
4
4

III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III
III

45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000
45000

360000
270000
405000
540000
225000
270000
225000
360000
315000
270000
180000
405000
315000
270000
450000
270000
315000
540000
225000
360000
180000
180000
180000
180000

59
Universitas Sumatera Utara

54.84.78
56.41.84
54.84.97
57.51.85

6
7
6
9

III
III
III
III

45000
45000
45000
45000

270000
315000
270000
405000

60
Universitas Sumatera Utara