Background The global emergence of antimicrobial resistance is driven by antibiotic misuse and overuse. However, systematic data in Indonesian hospitals to adequately inform policy are scarce. Objectives To evaluate patterns and quality indicators of antibiotic prescribing in six general hospitals in Jakarta, Indonesia. Methods We conducted a hospital-wide point prevalence survey (PPS) between March and August 2019, using Global-PPS and WHO-PPS protocols. The analysis focused on antibacterials (antibiotics) for systemic use. Results Of 1602 inpatients, 993 (62.0%) received ≥1 antimicrobial. Of 1666 antimicrobial prescriptions, 1273 (76.4%) were antibiotics. Indications comprised community-acquired infections (42.6%), surgical prophylaxis (22.6%), hospital-acquired infections (18.5%), medical prophylaxis (9.6%), unknown (4.6%) and other (2.1%). The most common reasons for antibiotic prescribing were pneumonia (27.7%), skin and soft tissue infections (8.3%), and gastrointestinal prophylaxis (7.9%). The most prescribed antibiotic classes were third-generation cephalosporins (44.3%), fluoroquinolones (13.5%), carbapenems (7.4%), and penicillins with β-lactamase inhibitor (6.8%). According to the WHO AWaRe classification, Watch antibiotics accounted for 67.4%, followed by 28.0% Access and 2.4% Reserve. Hospital antibiotic guidelines were not available for 28.1% of prescriptions, and, where available, guideline compliance was 52.2%. Reason for the antibiotic prescription, stop/review date and planned duration were poorly documented. Culture-guided prescriptions comprised 8.1% of community-acquired infections and 26.8% of hospital-acquired infections. Conclusions Our data indicate a high rate of empirical use of broad-spectrum antibiotics in Indonesian hospitals, coupled with poor documentation and guideline adherence. The findings suggest important areas for antimicrobial stewardship interventions.

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ObjectivesAntibiotic overuse is one of the main drivers of antimicrobial resistance (AMR), especially in low-income and middle-income countries. This study aimed to understand the perceptions and views towards AMR, antibiotic prescribing practice and antimicrobial stewardship (AMS) among hospital physicians in Jakarta, Indonesia.DesignCross-sectional, self-administered questionnaire-based survey, with descriptive statistics, exploratory factor analysis (EFA) to identify distinct underlying constructs in the dataset, and multivariable linear regression of factor scores to analyse physician subgroups.SettingSix public and private acute-care hospitals in Jakarta in 2019.Participants1007 of 1896 (53.1% response rate) antibiotic prescribing physicians.ResultsPhysicians acknowledged the significance of AMR and contributing factors, rational antibiotic prescribing, and purpose and usefulness of AMS. However, this conflicted with reported suboptimal local hospital practices, such as room cleaning, hand hygiene and staff education, and views regarding antibiotic decision making. These included insufficiently applying AMS principles and utilising microbiology, lack of confidence in prescribing decisions and defensive prescribing due to pervasive diagnostic uncertainty, fear of patient deterioration or because patients insisted. EFA identified six latent factors (overall Crohnbach’s α=0.85): awareness of AMS activities; awareness of AMS purpose; views regarding rational antibiotic prescribing; confidence in antibiotic prescribing decisions; perception of AMR as a significant problem; and immediate actions to contain AMR. Factor scores differed across hospitals, departments, work experience and medical hierarchy.ConclusionsAMS implementation in Indonesian hospitals is challenged by institutional, contextual and diagnostic vulnerabilities, resulting in externalising AMR instead of recognising it as a local problem. Appropriate recognition of the contextual determinants of antibiotic prescribing decision making will be critical to change physicians’ attitudes and develop context-specific AMS interventions.

Introduction A major driver of antimicrobial resistance (AMR) and poor clinical outcomes is suboptimal antibiotic use, although data are lacking in low-resource settings. We reviewed studies on systemic antibiotic use (WHO ATC/DDD category J01) for human health in Indonesia, and synthesized available evidence to identify opportunities for intervention. Methods We systematically searched five international and national databases for eligible peer-reviewed articles, in English and Indonesian, published between 1 January 2000 and 1 June 2021 including: 1) antibiotic consumption; 2) prescribing appropriateness; 3) antimicrobial stewardship (AMS); 4) perceptions among consumers and providers. Two independent reviewers included studies and extracted data. Study-level data were summarized using random-effects model meta-analysis for consumption and prescribing appropriateness, effect direction analysis for AMS interventions, and qualitative synthesis for perception surveys. (PROSPERO CRD42019134641) Results Of 9323 search hits, we included 100 reports on antibiotic consumption (20), prescribing appropriateness (49), AMS (13), and/or perception (25) (8 categorized in >1 domain). The pooled estimate of overall antibiotic consumption was 110.1 DDD/100 patient-days (95%CI98.5-121.6), with ceftriaxone, ampicillin and levofloxacin being most consumed. Pooled estimates for overall appropriate prescribing (according to Gyssens method) were 33.5% (95%CI18.1-53.4%) in hospitals and 49.4% (95%CI23.7-75.4%) in primary care. Pooled estimates for appropriate prescribing (according to reference guidelines) were, in hospitals, 99.7% (95%CI97.4-100%) for indication, 84.9% (95%CI38.5-98.0%) for drug choice, and 6.1% (95%CI0.2-63.2%) for overall appropriateness, and, in primary care, 98.9% (95%CI60.9-100%) for indication, 82.6% (95%CI50.5%-95.7%) for drug choice and 10.5% (95%CI0.8-62.6%) for overall appropriateness. The few AMS intervention studies conducted to date suggested potential to reduce antibiotic consumption and improve prescribing appropriateness. Key themes identified in perception surveys were lack of antibiotic knowledge among consumers and non-prescription antibiotic self-medication. Conclusions Context-specific strategies are urgently needed to improve rational antibiotic use in Indonesian hospitals and communities, with critical evidence gaps concerning private and informal health providers.

Objectives: To describe the use of bacterial cultures, and the etiology and antibiotic susceptibility of common high-priority bacteria isolated from hospitalized patients in Jakarta, Indonesia. Methods: We conducted a hospital-wide cross-sectional study of all inpatients receiving systemic antibiotic treatment (WHO ATC J01) in six hospitals in 2019, capturing routine data on antibiotic treatment and cultures. We reported bug-drug combinations for Escherichia coli and the ESKAPE group of bacteria. Results: 562 patients (52% women, median age 46 years) had 587 diagnoses, with pneumonia (258, 44%) most common. One or more culture specimens were taken in 38% (215/562) overall, a sputum culture in 25% (64/258) of pneumonia patients; and a blood culture in 52% (16/31) of sepsis patients. 50% of positive blood culture results were reported after ≥4 days. From 670 culture specimens, 279 bacteria were isolated, 214 (77%) were Gram-negative, including Klebsiella pneumoniae (70, 25%), Pseudomonas aeruginosa (36, 13%), and E. coli (21, 11%). Resistance included third-generation cephalosporin-resistant K. pneumoniae (77%), E. coli (65%) and Enterobacter spp (81%); carbapenem-resistant K. pneumoniae (26%), P. aeruginosa (24%), E. coli (33%), Acinetobacter spp (57%), and Enterobacter spp (60%); and meticillin-resistant S. aureus (71%). Vancomycin-resistant S. aureus (0%) and Enterococcus faecalis (12%) were uncommon. Multi-drug resistance was 30% for K. pneumoniae, 29% for P. aeruginosa, 49% for E. coli, 42% for Acinetobacter spp, and 71% for S. aureus. Conclusions: In Indonesian hospitals, bacterial cultures were underused and antibiotic resistance is at alarming levels. Enhanced context-specific infection prevention, diagnostic and antibiotic stewardship interventions are urgently needed.