Optimizing antibiotic use in Indonesia: A systematic review and evidence synthesis to inform opportunities for intervention

Antimicrobial resistance among common bacterial pathogens in Indonesia: a systematic review

Background

The WHO Global Antimicrobial Resistance Surveillance System (GLASS) aims to describe antimicrobial resistance (AMR) patterns and trends in common bacterial pathogens, but data remain limited in many low and middle-income countries including Indonesia.

Methods

We systematically searched Embase, PubMed and Global Health Database and three Indonesian databases for original peer-reviewed articles in English and Indonesian, published between January 1, 2000 and May 25, 2023, that reported antimicrobial susceptibility for the 12 GLASS target pathogens from human samples. Pooled AMR prevalence estimates were calculated for relevant pathogen-antimicrobial combinations accounting for the sampling weights of the studies (PROSPERO: CRD42019155379).

Findings

Of 2182 search hits, we included 102 papers, comprising 19,517 bacterial isolates from hospitals (13,647) and communities (5870). In hospital settings, 21.6% of Klebsiella pneumoniae isolates, 18.3% of Escherichia coli isolates, 35.8% of Pseudomonas aeruginosa isolates and 70.7% of Acinetobacter baumannii isolates were carbapenem-resistant; 29.9% of Streptococcus pneumoniae isolates were penicillin-resistant; and 22.2% of Staphylococcus aureus isolates were methicillin-resistant. Hospital prevalence of carbapenem-resistant K. pneumoniae and E. coli, and penicillin-resistant S. pneumoniae increased over time. In communities, 28.3% of K. pneumoniae isolates and 15.7% of E. coli isolates were carbapenem-resistant, 23.9% of S. pneumoniae isolates were penicillin-resistant, and 11.1% of S. aureus isolates were methicillin-resistant. Data were limited for the other pathogens.

Interpretation

AMR prevalence estimates were high for critical gram-negative bacteria. However, data were insufficient to draw robust conclusions about the full contemporary AMR situation in Indonesia. Implementation of national AMR surveillance is a priority to address these gaps and inform context-specific interventions.

Funding

Wellcome Africa Asia Programme Vietnam.

Factors associated with inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries: a systematic review and meta-analysis

BACKGROUND

Acutely ill children are at risk of unwarranted antibiotic prescribing. Data on the appropriateness of antibiotic prescriptions provide insights into potential tailored interventions to promote antibiotic stewardship.

OBJECTIVES

To examine factors associated with the inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries.

METHODS

On 8 September 2022, we systematically searched articles published since 2002 in MEDLINE, Embase, CENTRAL, Web of Science, and grey literature databases. We included studies with acutely ill children presenting to ambulatory care settings in high-income countries reporting on the appropriateness of antibiotic prescriptions. The quality of the studies was evaluated using the Appraisal tool for Cross-Sectional Studies and the Newcastle-Ottawa Scale. Pooled ORs were calculated using random-effects models. Meta-regression, sensitivity and subgroup analysis were also performed.

RESULTS

We included 40 articles reporting on 30 different factors and their association with inappropriate antibiotic prescribing. 'Appropriateness' covered a wide range of definitions. The following factors were associated with increased inappropriate antibiotic prescribing: acute otitis media diagnosis [pooled OR (95% CI): 2.02 (0.54-7.48)], GP [pooled OR (95% CI) 1.38 (1.00-1.89)] and rural setting [pooled OR (95% CI) 1.47 (1.08-2.02)]. Older patient age and a respiratory tract infection diagnosis have a tendency to be positively associated with inappropriate antibiotic prescribing, but pooling of studies was not possible.

CONCLUSIONS

Prioritizing acute otitis media, GPs, rural areas, older children and respiratory tract infections within antimicrobial stewardship programmes plays a vital role in promoting responsible antibiotic prescribing. The implementation of a standardized definition of appropriateness is essential to evaluate such programmes.

Clinical utility of procalcitonin in implementation of procalcitonin-guided antibiotic stewardship in the South-East Asia and India: evidence and consensus-based recommendations

INTRODUCTION

The South-East Asian (SEA) region and India are highly susceptible to antibiotic resistance, which is caused due to lack of antimicrobial stewardship (AMS) knowledge, uncontrolled use of antibiotics, and poor infection control. Nonadherence to national/local guidelines, developed to combat antimicrobial resistance, is a major concern. A virtual advisory board was conducted to understand the current AMS standards and challenges in its implementation in these regions.

AREAS COVERED

Procalcitonin (PCT)-guided antibiotic use was discussed in various clinical conditions across initiation, management, and discontinuation stages. Most experts strongly recommended using PCT-driven antibiotic therapy among patients with lower respiratory tract infections, sepsis, and COVID-19. However, additional research is required to understand the optimal use of PCT in patients with organ transplantation and cancer patients with febrile neutropenia. Implementation of the solutions discussed in this review can help improve PCT utilization in guiding AMS in these regions and reducing challenges.

EXPERT OPINION

Experts strongly support the inclusion of PCT in AMS. They believe that PCT in combination with other clinical data to guide antibiotic therapy may result in more personalized and precise targeted antibiotic treatment. The future of PCT in antibiotic treatment is promising and may result in effective utilization of this biomarker.

One Health approach and zoonotic diseases in Indonesia: Urgency of implementation and challenges

The urgency of implementing the One Health approach to overcome zoonotic diseases cannot be overstated. By recognizing the interconnectedness of human health, animal health, and the environment, we can effectively prevent and respond to emerging infectious disease threats. This review article provides information on the importance of generating research on zoonotic diseases, especially in Indonesia, where research is still relatively scarce. The Indonesian government has taken steps to implement the One Health by establishing the One Health Coordinating Unit and the National Zoonosis Committee; however, implementation has not been optimal. The urgency and challenges are focused on critical implementation aspects in the community. The urgency of implementing One Health includes that Indonesia has experienced several outbreaks of zoonotic diseases; high environmental degradation; and the antimicrobial resistance issue in Indonesia has increased. The challenges faced in implementing One Health are overcoming fragmentation due to incohesive communication between important sectors, securing funding and resource investment, aligning policies to eliminate regulation barriers, capacity building to increase awareness and professionals, and addressing critical socioeconomic factors. By prioritizing implementing the One Health approach and addressing existing challenges, Indonesia can build a more resilient and integrated system to protect the well-being of all species, protect ecosystems, and prevent the devastating effects of zoonotic diseases on global health. In this review, we present the urgency of One Health implementation and its challenges comprehensively.

Understanding Public Knowledge and Behavior Regarding Antibiotic Use in Indonesia

Background

Inappropriate use of antibiotics is a prominent factor contributing to the development of antibiotic resistance, which subsequently increases healthcare costs and heightens mortality rates.

Objective

This study sought to evaluate the level of knowledge and behavior pertaining to antibiotic usage within the Indonesian population.

Methods

This observational study was conducted in Indonesia between December 2019 and June 2020 and employed a validated questionnaire to survey 582 respondents. A comparative analysis was performed to investigate the differences in mean scores across various respondent characteristics, specifically related to their knowledge and practice regarding antibiotic usage. Regression analysis was used to identify the factors influencing the adoption of appropriate behavior in antibiotic utilization.

Results

Study participants comprised 68.2% males and 31.8% females. Participants achieved an average score of 4.86 ± 2.40 out of eight points for knowledge and behavior with an average score of 5.29 ± 1.85 out of seven points. Approximately 57.7% and 56.0% of the respondents have knowledge and behavior scores above the average score of the total population, respectively. The findings indicated notable variations in average knowledge scores associated with educational attainment and employment status regarding antibiotic use. Similarly, differences were observed in gender and employment status concerning behavior. Regression analysis highlighted that employment status, trust in physicians, and possessing sound knowledge of antibiotic usage were significant predictors of good behavior in utilizing antibiotics. Some misconceptions were identified, such as using antibiotics to kill viruses and believing antibiotics are effective for any kind of disease.

Conclusion

Less than 60% of the respondents have knowledge and behavior scores above the average score of the total population; however, there are some misconceptions regarding antibiotic utilization. This underscores the importance of implementing targeted strategies, such as health education and public health campaigns, to improve the population's understanding of the correct antibiotic use.

Contaminants of emerging concerns (CECs) in a municipal wastewater treatment plant in Indonesia

This study provides the first set of quantitative data on the occurrence and fate of a wide range of contaminants of emerging concerns (CECs) in Indonesia's largest wastewater treatment plant (WWTP). The WWTP employs waste stabilization ponds (WSPs) as the secondary treatment before discharging the effluent to the Citarum River. Fourteen out of twenty-two monitored CECs were detected in the wastewater influent, and seven were present in the effluent, with a total concentration of 29.8 ± 0.4 µg/L and 0.5 ± 0.0 µg/L, respectively. The occurrence of the CECs in this study was found to be well correlated with their possible use and known detection in surface waters in Indonesia. Caffeine (CAF) at 12.2 ± 0.1 µg/L, acetaminophen (ACT) at 9.1 ± 0.1 µg/L, N,N-diethyl-m-toluamide (DEET) at 5.0 ± 0.1 µg/L, ibuprofen (IBU) at 2.3 ± 0.0 µg/L, and triclosan (TCS) at 470 ± 64 ng/L were discovered as the five most prevalent CECs, followed by bisphenol A (BPA), trimethoprim (TMP), Tris(2-chloroethyl) phosphate (TCEP), sulfamethazine (SMZ), carbamazepine (CBZ), fluoxetine (FLX), benzotriazole (BTA), sulfamethoxazole (SMX), and metformin (METF). Biodegradable CECs (SMX, SMZ, ACT, IBU, TCS, BPA, CAF, DEET, and TMP) were efficiently removed (83-100%) by the WSP. In contrast, recalcitrant CECs achieved poor removal efficiencies (e.g., FLX at 24%), and for others, treatment processes even resulted in elevated concentrations in the effluent (CBZ by 85%, TCEP by 149%, and BTA by 92%). The CECs' influent concentrations were determined to pose a moderate aquatic cumulative risk, while no such risk was associated with their effluent concentrations. The study demonstrates the importance of conventional WWTPs in reducing the concentrations of CECs to minimize their aquatic contamination risk. The findings are relevant for countries, such as Indonesia, with limited resources for advanced centralized wastewater treatments, and which are exploring the efficacy of centralized WSP against the existing decentralized treatments.

Microbiomes in Acne Vulgaris and Their Susceptibility to Antibiotics in Indonesia: A Systematic Review and Meta-Analysis

Hot and humid countries such as Indonesia have a higher prevalence of acne vulgaris (AV). The activity of skin microbes, not only Cutibacterium acnes, contribute to the formation of AV. Topical and oral antibiotics are routinely prescribed to treat AV. As antimicrobial resistance rates increase globally, there are concerns about decreased efficacy. This study intends to systematically evaluate the microbiomes isolated from AV lesions and their antibiotics susceptibility in Indonesia. The data were retrieved through PubMed, EMBASE, Google Scholar, and ScienceDirect searches for articles published until July 2022 using three multiword searches. Sixteen studies published between 2001 and 2022 were identified from which the data were pooled using a random effects model. The pooled prevalence estimates demonstrated that C. acnes, Staphylococcus epidermidis, and Staphylococcus aureus were the three common microbes associated with AV in Indonesia. Tetracyclines had lower resistance rates compared to those of macrolides and clindamycin, with C. acnes showing a resistance rate that is as high as 60.1% against macrolides. C. acnes resistance against minocycline showed an increasing trend, whereas the resistances to doxycycline, clindamycin, and macrolides stagnated. The high resistance prevalence and trends signify a public health concern. The results of this study call for the development of antibiotic stewardship programs in Indonesia, which may lead to improved acne outcomes.