ORIGINAL ARTICLE

Bali Medical Journal (Bali Med J) 2019, Volume 8, Number 2: 474-479

P-ISSN.2089-1180, E-ISSN.2302-2914

The surveillance of antibiotics resistance in

Indonesia: a current reports
Published by DiscoverSys CrossMark
Andaru Dahesihdewi,1* Adhi Kristianto Sugianli,2 Ida Parwati2

ABSTRACT

Background: Antimicrobial resistance (AMR) has become a serious Antibiotic susceptibility pattern was slightly different among various
problem globally. Surveillance AMR is important to be part of the types of hospital and various clinical specimens. Positive Gram
quality indicator in antimicrobial stewardship program (ASP). This bacteria had good vancomycin susceptibility in all hospital types,
study aims to evaluate the AMR except in sputum from Type-A and B hospital, also in blood and
Method: Surveillance of microbial pattern and their antibiotics urine from Type-C hospital, similarly with linezolid susceptibility.
susceptibility in Indonesia 2017 was developed by the Indonesian Susceptibility pattern among Gram-negative- bacteria for
Association of Clinical Pathology and Laboratory Medicine. Data carbapenem and amikacin was good, in all hospital types, except on
aggregation was sourced from 31 hospitals antibiogram report which A. baumannii. For A. baumannii, antibiotic carbapenem, amikacin,
was joined the system of national data collection in forlabinfeksi.or.id and ceftazidime susceptibility were 20-66%, 35-80%, and up to
with standardized inclusion criteria. Data were analyzed descriptively, 83%, respectively. For P. aeruginosa, antibiotic susceptibility pattern
based on hospital type-A-B-C. was equal among all hospital types. Their susceptibility against
Result: There were 15.302 isolates included, 4.761 (31,1%) were cephalosporin (ceftazidime), fluoroquinolone (ciprofloxacin) and
positive Gram and 10.541 (68,9%) were negative Gram, 61,6% aminoglycoside (amikacin) were better in higher type-hospital.
reported by a type-A hospital, 16,4% by type-B and 22% by type-C. Conclusion: This result may become part of national epidemiological
Positive and negative Gram patterns respectively were E. faecalis data for ASP program evaluation. This data may also be referred for local
and E.coli (blood and urine), Streptococcus spp and K. pneumoniae empirical antibiotic guideline among limited resources appropriate
(sputum), S. aureus and E.coli (pus), E. faecalis and E.coli (wound), hospital. There will be improvement forward for more representative
coagulase-negative Staphylococcus and Enterobacteriaceae (CSF). beneficial data.

Keywords: surveillance, epidemiology data, antimicrobial resistance, empirical treatment

Cite this Article: Dahesihdewi, A., Sugianli, A.K., Parwati, I. 2019. The surveillance of antibiotics resistance in Indonesia: a current reports. Bali
Medical Journal 8(2): 474‑479. DOI:10.15562/bmj.v8i2.1386

1Department of Clinical BACKGROUND

Pathology and Laboratory
Medicine, Dr. Sardjito Antimicrobial resistance is microbial ability to E.coli and K .pneumonia were 25-57% and 32-56%,
Hospital/Faculty of Medicine, survive on antimicrobial exposure according to respectively.3
Public Health and Nursing, the anti-infection dosage.1 Antibiotic resistance is a Antimicrobial stewardship program is devel-
Universitas Gadjahmada,
Yogyakarta, Indonesia part of specific antimicrobial resistance in bacterial oped to prevent the emergence and spread of resis-
2Department of Clinical Pathology infection. Antibiotic resistance has become WHO’s tant microbial, so the infectious diseases treatment
and Laboratory Medicine Dr. concern, not only in every level of health service is expected can be optimal. The Global and National
Hasan Sadikin Hospital/Faculty of but also in various other sectors including livestock, Action Plan have been launched, approaching as
Medicine, Universitas Padjajaran, agriculture, and communities.1 One Health which is covered various aspects related
Bandung, Indonesia
The 2014 antimicrobial resistance surveillance to antimicrobial problems. An outcome indica-
reported by WHO shows that antibiotic resistance tor is needed to become program evaluation and
*
Correspondence to:
is a serious problem and has threatened the world improvement, both at global and national levels.4
Andaru Dahesihdewi;
Department of Clinical Pathology to enter the post-antibiotic era.2 In that era, it was Antibiograms in the hospital are developed
and Laboratory Medicine, Dr. feared that infectious diseases could no longer be periodically, standardized at least once a year,
Sardjito Hospital/Faculty of treated with available antibiotics. Treatment failure based on PMK 8, 2015 national regulation regard-
Medicine, Public Health and of the third generation of cephalosporins, fluo- ing the hospital Anti-Microbial Resistance Control
Nursing, Universitas Gadjahmada,
roquinolones, and carbapenems have reported in Program (PPRA). Based on the National Standard
Yogyakarta, Indonesia;
[email protected] several countries and have impacted in increased of Hospital Accreditation 2017, antibiogram must
morbidity, and mortality.2 Data reports on bacte- be prepared as one of the measurement elements
Received: 2018-11-19
rial pattern and it’s sensitivity in several hospitals in the ASP standard (National Program Standard
Accepted: 2019-05-08 in Indonesia have found methicillin-resistance of Group). This antibiogram is considered as the local
Published: 2019-08-01 S. aureus (MRSA) was 13-26%, ESBL producing Empirical Antibiotics Guideline.5

474 Open access: www.balimedicaljournal.org and ojs.unud.ac.id/index.php/bmj

 ORIGINAL ARTICLE

Many large hospitals, especially vertical hospitals anonymous; identities are only stored in a confiden-
in Indonesia, have carried out the best standards tial data management system and used when needed
microbiology laboratory service in accordance to confirm validity. There are no institution identities
with the International Guideline (the latest CLSI) in data analysis. There were several inclusion criteria
and National (Ministry of Health). Development of for aggregated data in each report used such as 1)
hospital microbial patterns and antibiogram thus Result of culture examination and antibiotic sensi-
can be maximal according to the best guidelines tivity test in suspected or clinical infection patients
and the needs of the local ASP team. Meanwhile, (colonization screening was excluded); 2) Valid
some other hospital, B-type and C-type hospital specimens (according to each type of the specimen);
that located across various regions and islands 3) Microbial are considered as pathogens that cause
in Indonesia (more than 2000 hospitals) provide infection (based on comprehensive expertise); and
microbiology laboratory services at varying levels of 4) Test method: manual or automatic method, with
methods according to limited resources, especially identification probability criteria ≥ 80% and the result
in facilities. Human resources of clinical laboratory of antibiotic sensitivity test is consistent.
specialist who have comprehensive competencies The microbial pattern and hospital antibiogram
in laboratory medicine, including microbiology at Indonesia in 2017 are grouped according to
laboratory service, are spread in all hospitals hospital type; those are a type-A hospital, type-B
throughout Indonesia to date.4 They have local hospital, and type-C hospital. Based on the loca-
microbial pattern data and antibiograms according tion/wards of patient care, the report is grouped
to the particular resources. The limitation of local into Intensive and Non-Intensive, except for type-C
antibiograms usually is caused by a low number hospitals. Type-C hospitals’ data were analyzed in
of examinations. The number of isolates tested for total wards due to limited available data. Based on
antibiogram reporting in one period is not represen- the specimen, the report is grouped into blood,
tative enough, minimal, and analysis is very simple. sputum, urine, feces, pus/abscess, cerebrospinal
The data of microbial patterns and antibiograms fluid (CSF), wound, and other body fluids.
reported by clinical pathology specialists in various Data aggregation involved Clinical Pathology
hospitals in Indonesia have to be potential standard- Specialists in 31 hospitals (22 government hospi-
ized and aggregated as national data to complete tals, 9 private hospitals), as follows: a) 5 vertical
the other data from various national programs that hospitals of health ministry; b) 2 hospitals in
have been and will be developed. Report of micro- Sumatera; c) 4 hospitals in Jabotabek; d) 4 hospitals
bial patterns and microbial sensitivity of antibiotics in West Java; e) 6 hospital in Central Java and DIY;
2017, was aggregated from 31 hospitals.4,5 Based on f) 6 hospitals in East Java; g) 3 hospitals in Central
those mentioned above, this report is the beginning Indonesia; and h) 1 hospital in East Indonesia
of a continuous process by Clinical Pathology and The report was a bacterial pattern and antibiotic
Laboratory Medicine Association for National AMR sensitivity pattern. The bacterial percentage is a
surveillance. This report can also be a part of the percentage (%) of the specific bacterial amount to
basic considerations for monitoring, evaluating and total bacterial included. Sensitivity percentage is
improving the National Programs. a percentage (%) of particular isolate amount that
sensitive to certain antibiotics among all the same
MATERIAL AND METHODS isolates tested. Data were analyzed using Microsoft
Excel for windows and presented in percentage.
Data is aggregated from the microbial pattern and
antibiogram report that is made by Clinical Pathology
RESULTS
Specialists incorporated in the antimicrobial resis-
tance data management system ‘forlabinfeksi.or.id.’ Microbial Pattern in Surveillance 2017
PDS PatKLin in 2017. Hospital identities are grouped The number of isolates reported was 15,302 consist-
by a system based on the type of hospital and region ing of 4,761 Gram-positive isolates (31.1%) and
(laboratory based). Aggregation and analysis data are 10.541 Gram-negative isolates (68.9%). The number

Table 1  Distribution of the number of isolates according to hospital type (2017 Surveillance Report)
Type-A Hospital Type-B Hospital Type-C Hospital
(n=9,423) (n=2,516) (n=3,363)
Non-Intensive Intensive Non-Intensive Intensive Total
Characteristic N (%) N (%) N (%) N (%) N (%) Amount
Gram (+) 2,037 (29.4) 708 (28.3) 746 (38.1) 142 (25.4) 1,128 (33.5) 15,302 (100)

Gram (-) 4,882(70.6) 1,796(71.7) 1,212 (61.9) 416 (74.6) 2,235 (66.5)

Published by DiscoverSys | Bali Med J 2019; 8(2): 474-479 | doi: 10.15562/bmj.v8i2.1386 475
ORIGINAL ARTICLE

Table 2  D
 istribution of the number of isolate types that are reported based on hospital types (2017 Surveillance
Report).
Type-A Hospital Type-B Hospital Type-C Hospital
(n=76) (n=42) (n=44)
Non-Intensive Intensive Non-Intensive Intensive Total
Characteristic N (%) N (%) N (%) N (%) N (%)
Gram (+) 20 (41.17) 13 (46.42) 15 (53.52) 8 (57.14) 15 (34.1)
Gram (-) 28 (58.83) 15 (53.52) 13 (46.42) 6 (42.86) 29 (65.9)

Table 3  The highest pattern of Gram (+) sensitivity based on hospital type (2017 Surveillance Report)
Type-A Hospital Type-B Hospital Type-C Hospital
NI INT NI INT Total
B U S B U S S S B U
BACTERIA AB %S %S %S %S %S %S %S %S %S %S
E.faecalis AMP 63.2 76.6 63.3 73.2 80 90 76.2
  SAM 92.3 63.7 76.6 88.9 74 80.4 100 90 78.9
  VAN 92.3 90.3 46.9 80 82.4 45.6 80 100 80
  CIP 50 18.9 18.8 27.3 17.6 35.7 60 75 27.8
  MXF 50 30.4 37.5 61.2 50
  LVX 46.2 23.1 30.4 65 34 66 100 85 33.3
  LNZ 100 91 30 80 90.9 67.3 100 91.7
S.aureus SAM 87.1 62.5 79.7 91.7 77.5 91.4 89.5 68.8
  AMK 80 100 66.7
  VAN 90.9 90 82.4 90.9 91.7 97,2 100 66,7
  CRO 74.5 75 78.1 83.3 69.6 91.4 89.5 67.6
  CZO 75 80.6 0.7
  CAZ 74.5 78.8 83.3 66.7 91.4 89.5
  CIP 78.6 66.7 75 75 58.3 83.3 81 72.7
  MXF 85.7 87.9 75 88.6 85.7
  DOR 90.6 92.3 93.8 100 91.4 89.5 71.4
  LVX 90.2 61.4 79.4 87.5 80.5 88.6 81 68.6
  LNZ 96.4 100 100 100 100 97.1 100 100
S.coag neg SAM 15.6 15 . 35.5 3.2
  AMK 60 36 88.9
  VAN 87.7 73.7 51.6 45.5
  CIP 36.4 0 6.5 42.3
  LVX 38.8 6.7 15.4 38.2
  TMP 10.5 66.7
  LNZ 96.9 88.9 93.5 85.7
B=blood ; U=urine ; S=sputum ; INT=intensive ; NI=non-intensive ; AMP=ampicillin ; SAM=ampicillin sulbactam ; AMK=amikacin ; VAN=vancomycin ;
CIP=ciprofloxacin ; LVX=levofloxacin ; MXF=moxifloxacin ; LNZ=linezolid

isolates reported from type-A hospitals were 9,423 for the type-C hospital cannot be specified due to
(61.6%), from type-B hospitals were 2516 (16.4%) limited information.
and from type-C hospitals were 3,363 (22%). The The number of isolates based on Gram char-
aggregate data distribution from 31 hospitals that acteristics in the three types of 31 hospitals is
contribute to this report is shown in Table 1. The shown in Table 2. Gram-negative bacteria are more
distribution of isolates and subsequent analysis commonly reported than Gram-positive, especially

476 Published by DiscoverSys | Bali Med J 2019; 8(2): 474-479 | doi: 10.15562/bmj.v8i2.1386
 ORIGINAL ARTICLE

Table 4  The highest pattern of Gram (-) sensitivity based on hospital type(2017 Surveillance Report)
Type-A Hospital Type-B Hospital Type-C Hospital
NI INT NI INT TOTAL
B U S B U S B U S S B U S
BACTERIA AB %S %S %S %S %S %S %S %S %S %S %S %S %S
E. coli AMP 12.5 16 3.8 11.5 18.2 6.5 88.2 27.3 7.7 14.8 12.2 2.3
  SAM 30.8 26.6 34.3 26 39.7 34.15 41.2 39.4 30.8 29.2 19.9 15.4
  AMK 99.3 92.4 92.2 100 85.7 88 100 100 100 100 97.4 93.2
  SXT 34.2 35 30.8 38.5 40.6 28.3 52.9   60 32.9 51.4
  CRO 31.5 33 20.3 . 39.4 15,6 70.6 66.7 38.5 53.6 50.8 8.9
  CAZ 32.9 34.8 23.1 15.4 38.2 20 70.6 66.7 38.5      
  CIP 30.1 29.8 34.6 26.9 29.4 33.3 66.7 51.5 30.8 60 41.3 17.5
  MRP 95.9 95.7 93.7 88.5 96.9 91.3 100 97 92.3 96.4 96.4 86.7
  DOR 100   100 100 96.9 100   100
  LVX 25 33.3 45.4 0 0 55.3 25 21.2 33.3
  FOS   100 100 83.3   100  
A. baumanii SAM 32 50.5 47.7 8.8 30.8 27.65 52.4 30.2 30.3 50 23.8
  AMK 35.8 79.1 57.2 40.5 76.9 54.7 63.5 56.8 46.3 66.7 34.9
  SXT 68.3 70.4 74.4 45.7 61.5 61.4 . 46.5 42.3 42.9  
  CRO 2.4 4.2 8,5 5,7 0 2.1 27 7 6,1 0 5.1
  CAZ 14.6 14.9 35 5.7 7.7 15.9 83.3 18.6      
  CIP 19.5 20.5 39,2 8,6 7,7 17,6 49,2 18,2 21,2 28,6 23,8
  MRP 42.9 66,2 53 20 30,8 21,9 52,4 29,5 27,3 46,7 21,4
  DOR 20   44,8 33,3   31,6 15,4
  LVX 21.4 66,7 32,4 25 34,5 100 0 25
P. aeruginosa AMK 75 65,9 78,1 76,5 80 69,3 75,7 57,9   65 61,2
  SXT   0 6 0 10 3,9 0   54,5 52,7
  CRO 0 4,2 6,5 20 0 10,9 0 0   0 0
  CAZ 66,7 61,4 69,6 52,9 80 50,3 7,3 52,6      
  CIP 62,5 60,2 64,8 64,7 80 48,6 60,8 47,4   44,4 47,7
  MRP 72 75,9 64,5 52,9 50 59 56,8 43,9   61,1 42,5
  DOR     85 100   83,3   33,3
  LVX 50 42,9 51,7 66,7 50 54,8 33,3 37,5
  FOS 100 62.5 59.3 0 100 45.8 100  
K. pneumonia SAM 15.4 32.7 34.7 1.4 36.1 18.8 17.1 40 67.5 51 9.5 22.1 26.3
  AMK 58.1 76.8 77.4 55.5 49.1 66.8 97.1 100 97.5 93.9 72.3 93.6 82.4
  SXT 37.5 42.9 57.3 1.2 26.9 26.8 20 50 . 55.1 41 38.7 41.2
  CRO 12.3 35.3 41.4 6.4 38.5 12.5 20 60 70.8 51 16.4 28.8 26.5
  CAZ 12.3 35.5 43.1 10.6 29.6 15.1 20 60 70.8 51      
  CIP 64.6 41.9 63.3 51.1 37 38.9 25.7 70 74.2 55.1 44.4 48.7 47
  MRP 88.9 89.1 93.6 8.2 76.9 78 48.6 90 95 91.8 65.7 91.5 69.2
  DOR     78 75   58.7 100   91,7
  LVX 52 47.7 58.2 40 80 53.2 75 33.3 76.2
  FOS   40 78.6 100 100 76.2   100  
B=blood ; U=urin ; S=sputum ; INT=intensive ; NI=non-intensive ; AMP=ampicillin ; SAM=ampicillin sulbactam ; AMK=amikacin ; SXT=cotrimoxasol ;
CIP=ciprofloxacin ; CRO=ceftriaxone ; CAZ=ceftazidime ; LVX=levofloxacin ; MRP=meropenem ; DOR=doripenem ; FOS=fosfomycin

Published by DiscoverSys | Bali Med J 2019; 8(2): 474-479 | doi: 10.15562/bmj.v8i2.1386 477
ORIGINAL ARTICLE

from urine. Major types of Gram-positive bacteria were sputum and blood, while specimens that were
are reported from sputum and blood. mainly received from non-intensive rooms were
The highest number of Gram-positive and nega- sputum and wound in addition to urine.9,10 The
tive bacteria in this study were E. faecalis and E. coli most Gram-negative caused bacteria in the inten-
(blood and urine), Streptococcus spp and K. pneu- sive room were K. pneumoniae, Pseudomonas spp,
moniae (sputum), S. aureus and E.coli (abscess/pus), and Acinetobacter spp, whereas in non-intensive
E. faecalis and E.coli (wounds), ­coagulase-negative rooms were E. coli and K. pneumoniae. The most
Staphylococcus and Enterobacteriaceae (LCS). Gram-negative bacterial pattern in a non-intensive
S.  Typhi and S. para-typhi isolates were found in type-B hospital is not different from Type-A hospi-
type-A and type-B hospitals, mainly from blood tal, whereas in intensive rooms analog patterns are
and urine. The sensitivity of both types of bacteria found which are slightly different in proportion.9,10
is good (≥ 80%) for many drugs including ampicil- The highest source of material for Gram-negative
lin, ciprofloxacin, and cotrimoxazole. bacteria from intensive rooms remains sputum
and blood, while for non-intensive rooms is more
Antibiotic Sensitivity Pattern in evenly sputum, wounds and pus, and urine and
Surveillance 2017 feces.
The bacterial susceptibility to antibiotics pattern, At Type-C Hospital, a description of the bacte-
in general, is slightly different between Type-A, B, rial pattern is carried out in total (without seeing
C and between specimens. The pattern of resistant the treatment room). The pattern of Gram-negative
bacteria is more commonly reported in type-A bacteria that causes infection is still analogous to
hospitals than the types below, both for Gram- the upper-type hospital, mostly K. pneumoniae,
positive and Gram-negative bacteria. Table 3 and followed by E. coli and Acinetobacter sp. The most
Table 4 show the most bacterial sensitivity patterns clinical material sources are sputum, urine, pus,
based on Gram characteristics, hospital type, wards, and blood. The Gram-positive bacterial pattern of
and specimen. the most common causes of infection is S. aureus
The sensitivity of Gram-positive bacteria to and S. epidermidis with the highest source of speci-
vancomycin is good in all hospital-types, except mens are blood, pus, sputum, and urine.9-12
for sputum in Type-A and Type-B hospitals, as The carbapenem and amikacin sensitivity of
well as the blood and urine in Type-C Hospitals. Gram-negative bacteria were relatively good in all
Similarly for linezolid antibiotics. The sensitivity hospital Type, except in A. baumanii. Among the
of Gram-positive bacteria to the beta-lactamase other Gram-negative bacteria, the carbapenem
combination antibiotics, ciprofloxacin, and levo- sensitivity range is 42.5-100%, while amikacin
floxacin tend to be low, up to Type-C Hospitals 60-100%. In this surveillance report, A. baumanii
(Table 3). showed a range of sensitivity to 20-66% carbape-
nem, to 83-80% amikacin and 83% to ceftazidime
in B-type hospitals. Pseudomonas aeruginosa
DISCUSSION
sensitivity to various classes of antibiotics is rela-
The Gram-positive bacterial pattern of infection tively equivalent among various types of hospitals.
in non-intensive rooms of Type-A Hospital is Its sensitivity to a cephalosporin (ceftazidime),
the same as in intensive rooms; most of them are fluoroquinolone (ciprofloxacin) and aminogly-
E.  faecalis and coagulase-negative Staphylococcus. coside (amikacin) were even better reported in
These Gram-positive bacteria are mainly-sourced higher type hospitals. The preferred antibiotics
from urine, sputum, and blood.6-8 Meanwhile, for P. aeruginosa infection were aminoglycosides
Gram-negative bacteria that cause the most infec- except for kanamycin and quinolones except
tions in intensive rooms are K. pneumoniae and moxifloxacin.9-12
Acinetobacter spp, while in non-intensive rooms are However, this study met several limitations
E. coli and K.pneumoniae. Gram-negative bacteria such as 1) representation of Clinical Pathology
are mainly-sourced from urine, sputum and wound Specialist contributions is still limited to 31
swabs.6-8 hospitals; 2) The analysis category is very general
Gram-positive bacteria with the highest because of limited information. MDRO pattern
number of infections in non-intensive rooms of (multi-drug resistant bacteria) and its sensitivity to
Type-B Hospital were dominated by coagulase-neg- antibiotics cannot be reported yet, and 3) Patterns
ative Staphylococcus and Streptococcus spp, slightly were described based on various capabilities in
different from the pattern in intensive rooms, each laboratory.
that were coagulase-negative Staphylococcus and Although there were many limitations, national
S.aureus. This is partly due to differences spec- surveillance report 2017 is still useful to be part
imens. In intensive rooms, the main specimens of national epidemiological data. That is expected

478 Published by DiscoverSys | Bali Med J 2019; 8(2): 474-479 | doi: 10.15562/bmj.v8i2.1386
 ORIGINAL ARTICLE

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AUTHORS CONTRIBUTION
This work is licensed under a Creative Commons Attribution
The authors are equally contributed to the manu-
script from data collection, statistical analysis, until
reporting the result of the study.

Published by DiscoverSys | Bali Med J 2019; 8(2): 474-479 | doi: 10.15562/bmj.v8i2.1386 479